This agreement contains important information about your clinician's professional services. 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). HIPAA requires that your clinician provide, you with a Notice of Privacy. The Notice, which is attached to this Intake Form explains HIPAA practices (the Notice) for use and disclosure of PHI for treatment, payment, health insurance and its application to your personal health information in greater detail. The law requires that your clinician obtain your signature acknowledging that you have been provided this information.
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the clinician and patient, and the particular problems you are experiencing. There are many different methods your clinician may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. It calls for a very active effort on your part. Psychotherapy can have benefits and risks. Since therapy often involves discussing difficult aspects of your life, you may experience uncomfortable feelings. On the other hand, psychotherapy is shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
The first few sessions together will involve diagnosis and an evaluation of your needs. By the end of the evaluation, your clinician, Kila Hillman-Sena MA, LPCC will be able to offer you some first impressions of what the work and treatment will include, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with her. If you have questions you should discuss them with her whenever they arise. If your doubts persist, she will help you set up a meeting with another mental health professional for a second opinion, if you wish.
Your clinician normally conducts an assessment that will last from 2 to 6 sessions. During this time, you and Kila can both decide if she is the best person to provide the services you need in order to meet your treatment needs. If psychotherapy is begun, individual therapy will generally be one 53 minute session per week and family and couples sessions will generally be one 45 minute session per week, although some sessions may be longer or they may more frequent if needed.
The private pay fee for professional services with Kila is $120.00 per session, including counseling appointments, report writing, telephone conversations, telehealth sessions, consulting with other professionals, with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request. Kila does not provide court services, as it is out of the scope of her practice. If she is sapeonaed and required to participate in court proceedings on your behalf, you will be expected to pay for that professional time, including preparation and transportation time. Your clinician charges $300.00 per hour for attendance at any legal proceeding. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. Insurance companies do not provide reimbursement for cancelled sessions.
CONTACTING YOUR CLINCIAN
Due to her work schedule, your clinician may not be immediately available by telephone. She will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform her of some times when you will be available. If you are unable to reach her and feel that you can’t wait for a return call, contact the Santa Fe Crisis line at 505-820-6333, call your family physician, call 911 or go to the nearest emergency room and ask for the clincian on call. If your clinician is unavailable for an extended time, she may provide you with the name of a colleague to contact, if necessary.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a mental health professional. In most situations, your clinician can only release information about your treatment to others if you sign an authorization form that meets certain legal requirements. There are other situations that require only that you provide written, advance consent. Your signature on this agreement provides consent for those activities, as follows:
• Your clinician may occasionally find it helpful to consult other health and mental health professionals. During a consultation, she will make every effort to avoid revealing the identity of her patients. The other professionals are also legally bound to keep the information confidential. If you don’t object, she will not tell you about these consultations unless they feel that it is important to your work together. Your clinician will note all consultations in your chart.
• You should be aware that your clinician practices with other mental health professionals, employees and administrative staff. In most cases, she may need to share protected information with these individuals for clinical or administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have received special training on how to protect your privacy and have sworn not to release any information outside of the practice without the permission of a professional staff member.
• Your clinician may also have contracts with business associates, such as bookkeepers and accountants. As required by HIPAA, she has formal business associate contracts with these businesses in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, he/she can provide you with the names of these organizations and/or a blank copy of this contract.
• Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement. There are some situations in which your clinician is permitted or required to 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 diagnosis and treatment, such information is protected by the therapist-patient privilege law. Your clinician cannot provide any information without your (or your personal or legally-appointed representative’s) written authorization, or a court order by a judge. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a judge would be likely to order her to disclose information.
• If a government agency is requesting the information for health oversight activities, your clinician may be required to provide it for them.
• If a patient files a complaint or lawsuit against your clinician may disclose relevant information regarding that patient in order to defend herself. There are some situations in which your clinician is legally obligated to take action. When she determines it is necessary to attempt to protect a patient or others from harm, she may have to reveal some information about a patient’s treatment. These situations are uncommon in your clinician's practice.
• If your clinician knows or has reasonable cause to believe that a child under 18 is an abused or a neglected child, the law requires that she immediately report the matter to an appropriate governmental agency, usually the Child, Youth and Family Department in the county where the child resides. Once such a report is filed, she may be required to provide additional information.
• If your clinician has reasonable cause to believe that an incapacitated adult is being abused, neglected or exploited, she must immediately report that information to Adult Protective Services. Once such a report is filed, she may be required to provide additional information.
• If your clinician believes that a patient presents a substantial and imminent risk of serious harm to another, she may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
• If a patient threatens a substantial risk or serious harm to himself, your clinician may be obligated to seek hospitalization for them, or to contact family members or others who can help provide protection if such a situation arises, your clinician will make every effort to fully discuss it with you before taking any action and she will limit their disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have now or in the future with your clinician. The laws governing confidentiality can be complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.
The laws and standards of our profession require that your clinician keep Protected Health Information (PHI) about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to him/her confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, your clinician recommends that you initially review them in the her presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, your clinician charges a copying fee of $.25 per page (and for certain other expenses). If your clinician refuses your request for access to your records, you have a right of review, which she will discuss with you upon request.
HIPAA provides you with several rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that your clinician amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and your clinician’s privacy policies and procedures. Your clinician will be happy to discuss any of these rights with you.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless your clinician agrees otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, your clinician may be willing to negotiate a fee adjustment or payment installment plan. For returned checks a $4.00 insufficient charge will be billed. If your account has not been paid for more than 120 days and arrangements for payment have not been agreed upon, your clinician has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the disclosure of otherwise confidential information. In most collection situations, the only information your clinician releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
MISSED APPOINTMENTS AND LATE CANCELLATION POLICY
• I understand that if I miss a scheduled appointment, or cancel less than 24 hours before the appointment, I am responsible for paying the cost of the appointment.
• I understand that if I miss an appointment, or do not cancel with 24 hour notice, which involves another party with whom I am sharing the cost, I am responsible for the total cost of the appointment.
• I understand that Kila is not able to bill my insurance for missed appointments and that I may be charged for the cost of that appointment.
• The standard fee for a missed session is $120 per session unless otherwise agreed upon by your clinician.
In order for us 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 clinician will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. 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. Your clinician will provide you with whatever information she can based on her experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, your clinician is willing to call the company on your behalf. 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 treatment 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 therapy after a certain number of sessions. While much can be accomplished in shortterm therapy, some patients feel they need more services after insurance benefits end. You and your clinician may discuss the options you have under such circumstances. Once your clinician has all of the information about your insurance coverage, she will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your therapy. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by contract.
You should also be aware that your contract with your health insurance company requires that your clinician provide it with information relevant to the services that are provided to you. Your clinician is required to provide a clinical diagnosis. Sometimes your clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, your clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. 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, your clinician has no control over what they do with it once it is in their hands. Your clinician will provide you with a copy of any report she submits, if you request it.
By signing this Clinician-Patient Services Agreement, you agree that your clinician can provide requested information to your insurance carrier, "I hereby authorize the release of medical information to my insurance company". If insurance claims are filed through this office, "I hereby authorize medical benefits for those services to be paid to this office.” Furthermore, it will also represent an agreement between us concerning the clinician-patient services agreements as outlined in this document, that your questions have been answered, and that you understand the written information provided above.