Patient Services Agreement
Welcome to The Center for Cognitive and Behavioral Therapy of Greater Columbus, Inc. (The Center). This document (the Agreement) contains important information about professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that you be provided with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that either you provide your signature acknowledging that you have been provided with this information before, or no later than the end of, your first session or that we made an attempt to obtain your signature. Although these documents are long and sometimes complex, it is very important that you read them carefully. You can discuss any questions you have about the procedures with either/or your Mental Health Provider, or one of The Center’s staff. When you sign this document, it will also represent an agreement between you, The Center, and your Mental Health Provider. You may revoke this Agreement in writing at any time. That revocation will be binding unless The Center, or your Mental Health Provider, has taken action in reliance on it; if there are obligations imposed on The Center or your Mental Health Provider by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. You will not be seen for treatment if you do not agree to the terms and conditions found in this Agreement.
MENTAL HEALTH SERVICES
Mental Health Services, which include, but are not limited to, provision of psychological services, professional counseling, marriage and family therapy, and psychosocial/social work services, are not easily described in general statements. These services vary depending on the personalities of the Mental Health Provider and patient, and the particular problems you are experiencing. There are many different methods that the Mental Health Provider may use to deal with the problems that you hope to address. Mental Health Services are not passive, unlike, for example, having an X-ray done. Instead, they call for a very active effort on your part. Many times, for the Mental Health Services to be effective, you might need to work on things addressed in your appointments, both in the sessions themselves, and outside the sessions.
You might receive services from an Independent Practicing Affiliate (IPA), who is an independent contractor of The Center. If so, The Center may provide the IPA with services including support and administrative services, which is based on a percentage of the fees received on behalf of the IPA, but The Center does not directly oversee the clinical services of the IPA, but the IPA has agreed to follow certain quality measures set by the Center and the IPA. Each IPA is licensed through a State of Ohio board, and complaints about the professional conduct of an IPA should be made to the appropriate board.
Mental Health Services might have benefits and risks. Since Mental Health Services often involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, Mental Health Services have also been shown to have many benefits. Mental Health Services have the potential to lead to better relationships, solutions for specific problems, and significant reductions in feelings of distress. But there are no guarantees about how you might react to the Mental Health Services, nor how beneficial the Mental Health Services will be.
Your first few sessions might involve not only treatment activities, but also an evaluation of your Mental Health Service needs. By the end of the evaluation portion of the Mental Health Services, your Mental Health Provider may be able to offer you some first impressions about what things would be likely be included in your Mental Health Services, including a plan for the Mental Health Services if you decide to continue. You should evaluate this information, and determine if you believe the fit between your Mental Health Provider and you will have a reasonable likelihood of benefiting you. Mental Health Services may involve a large commitment of time, money, and energy, so you should be very careful about the Mental Health Provider you select. If you have questions about the procedures the Mental Health Provider proposes, or eventually uses, you should discuss them with the Mental Health Provider whenever you identify the need to do so. If your doubts persist, you should feel free to obtain a second opinion from another Mental Health Provider and ask your Provider for the names of others from whom you can obtain a second opinion.
Please be advised that The Center has a policy that indicates that if a patient/client is a convicted or registered sex offender, that the patient/client cannot be provided services at any of the offices of The Center. The limitation is due to the following (in no particular order): a) The Center cannot guarantee the safety of clients/patients or staff against sexual assaults, b) The Center’s offices may be within sufficient distance of a school so that children might be at risk should a sex offender who victimizes children be in CCBT’s offices, and/or c) The Center does not include in its services the treatment of sex offenders.
WHO IS THE PATIENT/CLIENT?
Under recent rules related to HIPAA, and revisions to the AMA’s coding system (known as CPT codes), as well as State law changes, it has become necessary to be explicit about who is the patient, and who is not the patient. Patient and Client will be used interchangeably throughout this document. The definition impacts on financial responsibility, rights to records access, and other important facets of your rights and responsibilities. The patient is the person who signs the forms assuming financial responsibility, acknowledges receipt of HIPAA policies, and consents to treatment. Under the sections on Minors, and on Couples and Family therapy, there are further explanations of these issues related to treating minors, families, couples, and groups. For instance, someone signing for financial responsibility as a parent is not the patient if the child is designated as the patient. If someone attends a session in which you, or the child, is/are the patient, they are not defined as the patient unless they have specifically signed on as a patient. In that situation, they are a third party entering a session for a specific purpose.
APPOINTMENTS AND SESSIONS
Normally, a Mental Health Provider will conduct an evaluation during the first few sessions. During this time, the Mental Health Provider and you can both decide if that specific Provider is likely to provide you with the Mental Health Services in a manner you believe might produce desired outcomes. If further Mental Health Services are begun, the Mental Health Provider usually schedules sessions and appointments that can vary, for example, from 30-minute sessions, to 45 minute sessions, or to 60 minute sessions. However, the length of the session might vary depending on, but not exclusively due to, your particular Mental Health Service needs or for other reasons. Complicating factors may lead to additional complexity in any session (e.g., disruptions to communication, reporting of child abuse, hostility after divorce, etc.). When the complexity is above and beyond the typical expected level for a session, your Mental Health Provider may add a billing code to reflect this increased complexity, which may result in an additional charge. In addition to the length of the sessions, the Mental Health Provider and you may agree on the frequency of those sessions, which might include multiple sessions per week, weekly sessions, bi-weekly sessions, or other frequencies for the schedule of appointments. As with the length of sessions, the frequency of sessions might vary depending on factors such as, but limited to, your individual Mental Health Service needs. The Provider may, solely at the Provider’s discretion, use support staff
to schedule your appointments. Please note that typically insurance companies only pay for one session per week, so you would be responsible for paying for any sessions in a particular week in excess of one session.
Once an appointment hour is scheduled, your Mental Health Provider may ask you to pay for it, even if you miss the appointment, unless you provide at least 24 hours advance notice of cancellation. The Mental Health Provider has the option to not charge you, based on the particular reasons surrounding the missed session. It is solely at the discretion of the Mental Health Provider to decide if you will be charged for a missed session that was not cancelled at least 24 hour in advance. It is important to note that insurance companies typically do not provide reimbursement for cancelled sessions, thus you likely will be responsible for the fee personally.
PROFESSIONAL FEES
The Mental Health Providers at The Center charges an hourly fee of $190 for the initial psychological evaluative appointment. Subsequent psychotherapy sessions are billed at the following rates: 30 minute sessions--$80, 45 minute sessions--$120, 60 minute session--$160, increased complexity—an additional $10, crisis sessions--$190, family psychotherapy/couples therapy--$160, psychological testing--$160 per hour, neuropsychological testing--$160 per hour. In addition to weekly appointments, the Mental Health providers may charge $160 per hour for non-session Mental Health Services, though they typically prorate the hourly cost if the work is for periods of less than one hour, often, but not always, using tenths-of-one-hour periods that represent any portion of each six minute period. Other services include report writing, telephone conversations, consulting with other professionals when your case requires such consultations (although if appropriate, your permission will be sought prior to the consultations), preparation of records or treatment summaries, and any other service which is performed by the Mental Health provider.
If your Mental Health provider becomes involved in legal proceedings because of their treatment with you, you will be expected to pay for all of the Mental Health Provider’s professional time, including preparation and transportation costs and travel time, and you agree to pay such amounts, even if the Provider’s involvement is caused by someone other than you. Because of the increased difficulty of providing services in the context of legal involvement, the Mental Health Provider may charge $250 per hour for preparation and attendance, or other activities associated with any legal proceeding. Be advised that should the Mental Health Provider receive a subpoena for your records, or to provide any type of information related to court proceedings, including but not limited to testimony at a deposition, related to your work with the Mental Health Provider, you grant permission to the Mental Health Provider to contact an attorney of the Provider’s choosing, and you grant the Provider permission to share information about your case so that the attorney might provide appropriate legal advice on your situation and the legal issues involved. You will be charged for the time in contact with the attorney, and any legal bills generated, including, but not limited to, filing motions to quash, which are at the option of the Mental Health Provider. The exact amount of the fees involved when contacting an attorney under these circumstances will not be known until the time of the service, so the exact amount may not be disclosed to you until the Mental Health Provider knows the amount. In situations of potential harm to yourself (suicide) or others (injury or homicide – Duty to Protect), or suspected abuse or neglect of a child or elderly person or someone with limited competence, and in instances where the court or administrative agency may subpoena or order records (most commonly in contested divorce actions), the release of confidential materials may be legally required of your therapist. Also, if you report domestic violence, your therapist is required to note that in your clinical record.
CONTACTING YOUR MENTAL HEALTH PROVIDER
Due to the varying work schedules of Mental Health Providers at The Center, the Providers may not be immediately available by telephone. While The Center is usually open between 8 AM and 5 PM, it is closed between 11:30 AM and 12:30 PM, and is closed on certain holidays or during calamities. The Mental Health Provider probably will not answer the phone when the Provider is with a patient. Generally speaking, only arranged telephone appointments will ensure contact at a specific time. When the Provider is unavailable, the office telephone is answered by voicemail. On the voicemail, there may be additional information about contacting the Mental Health Provider in case of an emergency, defined as a threat of harm or death to either yourself or someone else. Please be advised that The Center is an outpatient practice and is not a hospital, and cannot guarantee it will provide 24-hour, seven day per week coverage. While you may contact the emergency number listed on the Provider’s voicemail, the Provider may not be able to return the call as quickly as you might need the Provider to call, and therefore you should contact 911 or go to your local emergency room immediately after using any emergency contact procedure that might be provided on the office voicemail. The Mental Health Provider may attempt to contact you based on his/her procedures, but you should always take steps to ensure your safety, or the safety of others, despite any calls placed to the Mental Health Provider. The Center does not provide “on-call” services, meaning that if you call and make a request for either follow-up services from your Provider, or emergency services, The Center does not provide additional Mental Health Providers to deliver Services beyond your own Mental Health Provider. Any coverage by a different Mental Health Provider should be arranged by you and the other Mental Health Provider. Again, your Mental Health Provider is responsible, not The Center, for following-up on requests you might have between appointments for any type of Mental Health Services.
Voicemails are the responsibility of the Mental Health Provider. If you believe you have waited longer than you should for a return call, you can contact The Center, and we will attempt to inform your Provider; but The Center is not responsible for any provider’s obligation to return your calls. Again, The Center cannot guarantee to resolve your concern about messages, even if The Center might try to undertake efforts to resolve your concerns. If the Mental Health Provider will be unavailable for an extended time, the Provider usually will notify you, if such notification is possible, and you should make sure to request from the Provider the procedures to use during the Provider’s absence should unanticipated needs arise. Again, The Center is not responsible for ensuring you have been informed about extended absences of your Provider. Please make any request for “what to do” in writing so there is a record of it for both you and the Provider.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of communications between a patient and a Mental Health Provider. In most situations not involving treatment, payment or health care operations, the Mental Health Provider can only release information about your treatment to others if you sign a written authorization form that is consistent with requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. In most instances only the minimum information necessary to accomplish a specific purpose will be disclosed. Your signature on this Agreement provides consent for those activities, as follows:
--The Mental Health Provider may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, the Provider makes good-faith efforts to avoid revealing the identity of a patient. The other professionals are also legally bound to keep the information confidential. Unless you object in writing, the Provider might not tell you about these consultations unless the Provider decides that it is important to the provision of Mental Health Services to you. The Provider may note consultations in your Clinical Record.
--You should be aware that the Mental Health Provider practices with other mental health professionals at The Center, and that The Center employs administrative and support staff. The Mental Health Provider will typically need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same, or similar, rules of confidentiality. All staff members have received training about protecting your privacy, and have agreed not to release any information outside of the practice without the permission of a professional staff member.
--The Center, and your Mental Health Provider, also may have contracts with other professionals, including but not limited to, attorneys, accountants, billing services, software companies, insurance companies, collection companies, and other entities. As required by HIPAA, The Center, or in some cases the Mental Health Provider as well, if required, has a formal business associate contract with this/these business(es), in which it/they promise to maintain the confidentiality of the data involved, except as specifically allowed in the contract, or as otherwise required or allowed by law.
--Texting, emailing, and even phone conversations using the internet for service, as well as other electronic communications may not be a confidential form of communication if they are unencrypted. If you use any of these ways to communicate with The Center and/or its Providers or administrative staff, please be aware that The Center, and its employees or contractors, cannot guarantee the security of the unencrypted information. If you decide to utilize such unencrypted services, you agree to accept those risks.
--Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations where the Mental Health Provider may, or must, disclose information without either your consent or Authorization:
--If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is generally protected by laws that establish a privilege. If privilege applies, the Mental Health Provider cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in, or are contemplating, litigation, you should consult with your attorney to determine whether a court would be likely to order the Mental Health Provider, or The Center, to disclose information. For purposes of this paragraph, litigation, or courts making orders, is meant to include, but not be necessarily limited to, municipal/local courts, state courts, federal courts, as well as administrative legal proceedings. In addition, please be aware that in some state courts in Ohio, judges have ruled that if you place custody of minor children as an issue within a domestic, or juvenile, or probate court proceeding (for example, a divorce, a dissolution, or are contesting the rights to parent when not married), this may constitute a waiver of privilege or expectation of confidentiality for any mental health records about you, including those records that predate your litigation. Also, if you are a party to civil litigation, such as, in a personal injury claim or other type of proceeding, and you, or someone else, makes your mental health or mental distress an issue in the litigation, your privilege may be waived and/or confidentiality might be limited.
--If a government agency is requesting the information for health oversight activities, The Center, or the Mental Health Provider, may be required to provide it to them.
--If a patient files a complaint or lawsuit against The Center, or the Mental Health Provider, The Center or Provider may disclose relevant information regarding that patient in order to defend against the allegation.
--If a patient files a worker’s compensation claim, the patient will, in the typical case, execute a release so that the Mental Health Provider may release information, records or reports relevant to the claim.
There are some situations in which the Mental Health Provider may be legally obligated or allowed to take actions which the Mental Health Provider believes are necessary to attempt to protect others from harm; and the Provider may have to reveal some information about a patient’s Mental Health Services. The typical situation in an office like
The Center’s might be:
--If the Provider knows, or might have reason to suspect, that a child under 18 years of age, a developmentally disabled, or physically impaired person either under 21 years of age, or a developmentally disabled or elderly adult, has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably suggests any form of abuse or neglect of the individual, the law requires that the Mental Health Provider file a report with the appropriate government agency. Once such a report is filed, the Provider may be required to provide additional information.
--If the Mental Health Provider reaches an opinion that a patient presents a clear and substantial risk of imminent serious harm to him/herself, a specific individual that can be identified, or to property, the Mental Health Provider may need to disclose certain information that may serve to protect the patient, the specific individual or the property at-risk for harm. The Mental Health Provider may need to disclose that information to appropriate public authorities, and/or the potential victim, and/or take other steps to minimize the risk of harm.
--If a minor is in treatment, with very limited exceptions that are described in the Notice of Privacy Practices or in Ohio’s privilege statute, the Mental Health Provider usually must reveal information about the minor’s Mental Health Services to the minor’s parents. If the minor’s parents are divorced, both parents may have access to information about the minor’s services regardless of custodial arrangements, unless a court-order specifies limitations to a parent’s access to that information. Both parents will also typically be provided with information supplied by the other parent if the child is the only client. If such a court documents exists on the minor, please provide a copy to your Mental Health Provider. This is discussed more later in the Minor section.
If such a situation arises, the Mental Health Provider may make efforts to discuss with you the possible release of confidential information before taking any action, if such a preliminary discussion is possible and appropriate, in the opinion of the Mental Health Provider. The Provider will attempt to limit the disclosure to what is minimally necessary, but understand the Provider might not be able to discuss with you the need to disclose the information, and if not, the Mental Health Provider still may disclose the information.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential limitations, it is important that you and your Mental Health Provider discuss any questions or concerns that you may have now or in the future. The laws and rules governing confidentiality can be quite complex, and neither The Center nor your Mental Health Provider can provide legal advice. In situations where specific advice is required, formal legal advice may be needed, and you should contact your attorney. Should you have questions about these limitations to confidentiality, please try to provide them to the Mental Health Provider in writing in advance of any appointments or contacts.
PROFESSIONAL RECORDS
You should be aware that, pursuant to HIPAA, the Mental Health Provider may keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history (any past PHI or Mental Health Service Notes received from other providers), reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. With rare exception, if your mental health provider determines for clearly stated treatment reasons that disclosure may have an adverse effect on the patient, in which case you may select another mental provider and the records will be sent to that provider, you may examine and/or receive a copy of your or your child’s Clinical Record if you request them in writing, and the request is signed by you and dated not more than one year from the date it is submitted. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, it is recommended that you initially review them with your Mental Health Provider, or have them forwarded to another Mental Health Provider so you can discuss the contents. Your provider owns these records if they are an IPA, not CCBT, and should your IPA provider leave The Center, he/she will take these records with him/her and your access to those records will be the responsibility of your provider, not CCBT. If your provider is an employee of CCBT, then CCBT will always maintain the records in accordance with applicable records retention requirements.
In most circumstances, The Center may charge a copying fee which varies from year to year, depending on what is allowed under state and federal law. The fee for copying your records is payable in advance, and the fee is typically paid by you, not any third party you wish the records sent to. These amounts may also increase yearly based on data developed by the Ohio Department of Health. If you request your records in an electronic format and we maintain it in that format, then we can send it to you that way. Please be advised that your records may be reviewed by you, or anyone that you release them to, on the premises at The Center, at no charge. The Center will provide support staff to supervise the records review. A request for a records review should be made in advance, received at least 5 business days prior to the need for the records to be reviewed, and the request must be in writing, signed by you or your designee.
The Mental Health Provider also may keep a second set of records, often known as Psychotherapy Notes. Psychotherapy Notes are be defined as those notes, described in what follows, kept by any Mental Health Provider at The Center, regardless of the Provider’s particular discipline or license (for example, Licensed Independent Social Worker, Psychologist, Professional Counselor, Psychiatrist, etc.). These Notes are for the Provider’s own use and are designed to assist the Provider in providing you with adequate treatment. While the contents of Psychotherapy Notes vary from client to client, they may include the contents of information shared during sessions or an analysis of that information. The Psychotherapy Notes may also contain particularly sensitive information that you may reveal to the Mental Health Provider that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept on a form separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they might not be able to receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies may not be able to penalize you in any way for your refusal to sign an authorization for claims payment purposes. Please be advised that the same conditions for copying costs and review as noted earlier in this section apply to copying or reviewing Psychotherapy Notes. Some Mental Health Providers may not create Psychotherapy Notes, and then records of all Protected Health Information would be in your files. In all instances, Ohio law provides a right for a mental health provider to deny a client (or parent if the client is a child) direct access to records when they determine that releasing the records directly to you would have an adverse impact on the client, in which case you can name another mental health professional to which the records will be sent.
PATIENT RIGHTS
HIPAA provides for rights with regard to your Clinical Record and disclosures of PHI. These rights may include requesting that the Mental Health Provider, or The Center in some cases, amend your record; requesting restrictions on what information from your PHI is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized or that are not released for treatment, payment or health care purposes (the latter would be available if your Provider utilizes electronic records); the right to file any complaints about the policies and procedures of the Provider or The Center; and the right to a paper copy of the attached Notice form. Your Mental Health Provider would be willing to discuss any of these rights with you.
COUPLES, FAMILY, OR GROUP SERVICES OR WHEN A THIRD PARTY IS PRESENT IN AN INDIVIDUAL SESSION
Couples therapy is distinct from individual therapy which occasionally involves the presence of another person (such as a spouse, partner, family member or friend). When mental health services are delivered to an individual for individual problems, those services are not considered couples therapy even if another person is occasionally present, since the focus of treatment is on the individual patient (AMA, 2012). Couples therapy where both parties are clients is generally not covered by insurance and if you seek couples therapy you agree to pay for the services out of pocket in that case.
In family therapy, all persons are considered patients and all adults must sign in as clients. They may or may not all be given a diagnosis. In that situation, the therapy will be billed as family therapy.
In any mental health service during which more than one person is present, there are specific limitations on the confidentiality rights of, and privilege held by, the various individuals involved. There are issues involving the right to have access to the treatment notes, during or after the treatment or consultation sessions when a legal proceeding is underway—this is the issue of privilege. In Ohio, because more than just the mental health provider and one patient may be in the room, there may be limits to the protection of the information shared in these situations. You should be aware of who holds the privilege and who has the right to confidentiality and who may obtain access to and/or release the records.
Also, there are limits to how effectively the mental health provider can maintain the confidential nature of the information you share in individual psychotherapy, couples therapy, or consultation sessions where more than one person is involved in the mental health sessions. These limits have to do with the presence of people other than you and the mental health provider and the potential that those other people could share information you reveal during the sessions. Also, there may be limits to how effectively the mental health provider can protect that information if you, or someone else, in these sessions requests records or information from these sessions, depending on who, and who is not, a patient.
It is CCBT’s policy to typically attempt to do the following:
• Maintain records of the couples sessions as joint records if all of the persons are patients (that is, all those present have signed a Patient Services Agreement and an acknowledgement of receipt of our HIPAA statement, or an attempt to obtain that acknowledgement). In this situation insurance will typically not reimburse for this type of therapy. In couples therapy, each patient holds a privilege and has the right to confidentiality of the information that patient provides, or which is generated as a record by the therapist in the notes about that patient. Only that person may therefore release, or access, that patient’s own information. It is important to note that any one patient in couples sessions may not release, or access, the information of other patient also present in couples sessions;
• Maintain records of an individual patient’s progress in group treatment or consultations, and in those records not address, by name, any other patient’s comments or behaviors;
• Release only those sections of records from couples or family sessions related to any given patient who executes a release form, and attempt, to the best of any provider’s ability, to redact (black out) information about any patient in a couples or family session who has not signed a release. Note that in family sessions, if there are minors present, typically both parents have access to the minor patient(s) records unless blocked by court order;
• Require only the individual patient in group sessions, wishing to release records of any given session, to sign a release form to authorize the release of confidential information from group sessions regarding only that individual patient;
• Release any patient’s self-generated and written information regardless of the treatment setting, if that individual signs a release form authorizing release of that information; and only under the condition that the to-be-released information (for example, but not exclusively, a client information form, psychological test results) is generated solely by or for that individual;
• Release information in the records about others present in any type of mental health session, if those others are not patients, if and only if the patient signs a release of information; and
• Comply with other laws, court orders, or other requirements listed separately in informed consent forms or the Notice of Privacy Practices form used by The Center, its employees or IPAs that require or may cause the release of confidential information.
If a non-patient is requested by you to attend any type of mental health service, your therapist is responsible to inform the non-patient that a) the non-patient has no right of confidentiality or privilege involving any session attended, and b) only the patient, i.e. you, has a right to confidentiality or privilege of all information related to mental health services since any non-patient who attends a mental health session is not a patient, and that person may not access any records. Your therapist will make any non-patient, who attends any of your mental health sessions, aware that any record related to the provision of mental health services to you is controlled by you, the patient.
All non-patients attending mental health sessions are typically asked to agree not to share the information obtained in the sessions, and it is the responsibility of your therapist to obtain that agreement with a non-patient who might attend a session. You, as the patient, also agree, however, that the mental health provider cannot guarantee that non-patients attending a mental health session will honor that assumption and agreement. It will sometimes be the case that your mental health provider will request you, the patient, sign an additional form regarding the presence of a third party in a session.
Please note that most parents control their children’s confidentiality and privilege, unless there is a court order stating otherwise. So, if the child(ren) is/are the identified patient(s), then both parents have the right to access information provided by the other parent in connection with therapy provided to the child(ren), unless one or both parents are also patients.
MINORS
Patients under 18 years of age who are not emancipated, and their parents, should be aware that parents are permitted to examine their child’s treatment records. A special law does, however, allow children between 14 and 18 to independently consent to, and receive up to, 6 sessions of Mental Health Services (provided within a 30-day period), paid for by the minor, and no information about those sessions can be disclosed to anyone without the child’s agreement with some limited exceptions. While privacy in Mental Health Services is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For teenage children, a Mental Health Provider may have a policy to request an agreement in which the parents agree not to request any of their child’s records. However, regardless of that agreement having been negotiated, except for the exception noted earlier in this paragraph which provides the child with some confidentiality rights, parents are generally entitled to access the information and records derived from the provision of Mental Health Services to minor children and they have the right to revoke their consent to such an agreement. As noted earlier in this Agreement, when parents are divorced, non-custodial or non-residential parents are permitted access to the same information and records as are custodial or residential parents unless expressly limited from that information or those records by an order from a court. All minor children will be advised of these rights, particularly if the parents sign an agreement not to access a child’s records and then later change their minds.
Only parents who have the authority to consent to treatment for a child/adolescent may sign forms and commit to that child’s or adolescent’s receipt of Mental Health Services. Divorced parents or legally separated parents should bring to their first session their divorce decree or other court documents which state who may seek treatment for their child(ren) and who has the responsibility for payment. When the parent who brings the minor to The Center for Mental Health Services is divorced or legally separated, then their signature on this form creates an obligation to pay for Mental Health Services provided to the named minor; unless and only if, the parent provides to The Center information indicating they are not responsible. If such information is provided, Mental Health Services will be delivered only if the party otherwise responsible signs forms creating an obligation to pay AND ONLY IF that other party arranges for payment in accordance with The Center’s policies then in effect.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, whether you are responsible for the full fee or a co-payment, depending on the status of any Third Party Payment options available to you. The Center may not permit a person receiving Mental Health Services through Providers at The Center to incur an unpaid fee balance which lasts longer than 90 days, where the individual is personally responsible (for example, if you make $25 co-pays but otherwise have your bill paid by a Third Party Payer, the 90 day limit applies to unpaid co-pays, or if you pay cash for your Services, then the 90 day limit applies to the entire fee charges). Payment schedules for other professional services will be agreed to when they are requested.
Provision for the use of automatic payment of amounts owed by a patient, can be found in a separate form.
If your account remains unpaid after reasonable attempts have been made by The Center to collect the balance from you, and after the 90 period has run, The Center and your provider may exercise the option of using legal means to secure the payment. The Center and your therapist will have discretion to determine when a reasonable effort has been made, and when to enlist the aid of other legal means. This may involve hiring a collection agency or going through small claims court which will require The Center, and/or the Mental Health Provider, to disclose otherwise confidential information. In most collection situations, the only information that would be released regarding a patient’s Mental Health Services is his/her name, the dates of service and the amount due.
INSURANCE REIMBURSEMENT
In order for you and the Mental Health Provider to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Your Mental Health Provider will fill out forms and provide you with whatever assistance the Provider can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of the fees. It is very important that you find out exactly what mental health services your insurance policy covers. While The Center will also attempt to determine the coverage available to you, information obtained by The Center cannot be guaranteed to be accurate, since it is obtained typically through phone calls or mail from others, such as Benefits Managers or insurance companies which may not provide accurate information. Ultimately, you are responsible to ensure that any Third Party Payer, whom you believe to be responsible for a portion or all of your bills, makes the payments. Otherwise, you will be responsible for the costs of the Mental Health Services.
You should carefully read the section in your insurance coverage booklet that describes Mental Health Services. If you have questions about the coverage, call your plan administrator. The Center, or your Mental Health Provider, will provide you with whatever information they might have available, based on experience. You may request that The Center, or your Provider, discuss your coverage and service with an insurance company, but should those discussions occur, you may not receive all relevant information from them since your insurer’s cooperation or accuracy cannot be guaranteed.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for Mental Health Services. These plans are often limited to short-term service approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more Mental Health Services after a certain number of sessions. While much can be accomplished with short-term services, some patients feel that they need more services after insurance benefits end. Some managed-care plans may try to prohibit, or expressly forbid, the Mental Health Provider from continuing to provide services to you once your benefits end. If this is the case, your Provider may try to find another provider who will help you continue your Mental Health Services.
You should also be aware that your contract with your health insurance company requires that The Center, and/or your Mental Health Provider, provide it with information relevant to the services that you are provided. In the typical case, The Center, and/or your Provider, may be required to provide a clinical diagnosis. Sometimes the insurer requires that additional clinical information be provided, such as treatment plans or summaries, or copies of your entire clinical record. When the insurer requires such information to be released, this information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, neither The Center nor your Mental Health Provider has control over what the insurer does with the information once it is in their hands. In some cases, they may share the information with a national medical information databank. You may request, in writing, a copy of forms submitted by your Mental Health Provider to an insurer. By signing this Agreement, you agree that The Center, and your Mental Health Provider, can provide insurer-requested information to your carrier.
Be aware that some carriers require subscribers to respond to requests for additional information, such as verification that the carrier is the sole health insurer for the patient. If you fail to respond to your insurance company’s request for additional information, your claim may be denied and you may become personally responsible for the fees.
Based on the level of insurance coverage available to you, you may request that you and your Mental Health Provider discuss what can be expected to be accomplished with the benefits that are available, and what might happen if the benefits run out before you feel ready to end your Mental Health Services. It is important to remember that you always have the right to pay for Mental Health Services yourself to avoid the problems described above unless prohibited by contract between either The Center or your Mental Health Provider and your insurer. Under changes to HIPAA in 2009, you now have the right to elect not to use insurance when seeing a therapist and then no information will be disclosed to your insurance company. You should be aware, however, that you have to make that election prior to each therapy service. You will be charged allowable fees under such circumstances and you must pay those at the time of the request.
SECONDARY INSURANCE
Please be aware that The Center does not submit secondary insurance claims as a general policy of the office. Secondary insurance policies are typically found where coverage is available through two insurance companies, e.g. if both a husband and wife each have coverage for the entire family. If you would like to use a secondary insurance carrier, it will be the responsibility of the patient to submit their own claims forms to request reimbursement for the costs of services. We apologize for any inconvenience this might create.
If you are a Medicare Patient and Medicare files a “cross-over” claim with Medicaid, CCBT does not generally accept payments from Medicaid. CCBT will not have billed Medicaid in those cases, and you will still be responsible for your co-payment.
DISCLOSING INFORMATION TO FAMILY MEMBERS, RELATIVES, OR CLOSE FRIENDS
Unless you object in writing, by signing below you agree to allow your therapist, if you are incapacitated, in an emergency situation, or are otherwise not available, to contact a family member, a relative, a close friend or any other person you identify, to disclose your personal health information that directly relates to that person’s involvement in your healthcare. This information will be disclosed as necessary only if your therapist determines that it is your best interest based on his or her professional judgment.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during your relationship with The Center and your Mental Health Provider.
If you refuse to sign this form, or fail to provide a signed copy to the Center, you will be refused services by The Center, its employees, and/or its IPAs.