TRIAL, COURT ORDERED APPEARANCES, LITIGATION: Rarely, but on occasion, a court will order a therapist to testify, be deposed, or appear in court for a matter relating to your treatment or case. In order to protect your confidentiality, I strongly suggest not being involved in the court. If I get called into court by you or your attorney, your attorney or yourself will be invoiced a $1500 retainer, requiring payment within 5 days. Boundless Hope services will be billed at a fee of $275/hour to include travel time, court time, preparing documents, etc.
COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records, a treatment summary will be provided at the cost of one session. Payment for your treatment summary will be due prior or upon receipt and can be picked up at the office. Please allow at least 2 weeks to prepare.
PHONE CONTACTS AND EMERGENCIES: Office hours vary by clinician. If you need to contact the clinician for any reason please call them, leave a voicemail, and a return call will be made as soon as possible. In case of an emergency, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255. If either you or someone else is in danger of being harmed, dial 911. Understand that your clinician does NOT provide emergency services.
PART II: CONFIDENTIALITY:
Anything said in therapy is confidential and may not be revealed to a third party without written authorization, except for the following limitations:
● Child Abuse: Child abuse and/or neglect, which include but are not limited to domestic violence in the presence of a child, child on child sexual acting out/abuse, physical abuse, etc. If you reveal information about child abuse or child neglect, I am required by law to report this to the appropriate authority.
● Vulnerable Adult Abuse: Vulnerable adult abuse or neglect. If information is revealed about vulnerable adult or elder abuse, I am required by law to report this to the appropriate authority.
● Self-Harm: Threats, plans or attempts to harm oneself. I am permitted to take steps to protect the client’s safety, which may include disclosure of confidential information.
● Harm to Others: Threats regarding harm to another person. If you threaten bodily har or death to another person, I am required by law to report this to the appropriate authority.
● Court Orders & Legal Issued Subpoenas: If I receive a subpoena for your records, I will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information. I will contact you twice by phone. If I cannot get in touch with you by phone, I will send you written correspondence. If a court of law issues a legitimate court order, I am required by law to provide the information specifically described in the order. Despite any attempts to contact you and keep your records confidential, I am required to comply with a court order.
● Law Enforcement and Public Health: A public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability; to a health oversight agency for oversight activities authorized by law, including audits; civil, administrative, or criminal investigations; inspections; licensure or disciplinary actions; civil, administrative, or criminal proceedings or action; limited information (such as name, address DOB, dates of treatment, etc.) to a law enforcement official for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person; and information that your clinician believes in good faith establishes that a crime has been committed on the premises.
● Governmental Oversight Activities: To an appropriate agency information directly relating to the receipt of health care, claim for public benefits related to mental health, or qualification for, or receipt of, public benefits or services when a your mental health is integral to the claim for benefits or services, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.
● Upon Your Death: To a law enforcement official for the purpose of alerting of your death if there is a suspicion that such death may have resulted from criminal conduct; to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties as authorized by law.
● Victim of a Crime: Limited information, in response to a law enforcement official's request for information about you if you are suspected to be a victim of a crime; however, except in limited circumstances, we will attempt to get your permission to release information first.
● Court Ordered Therapy: If therapy is court ordered, the court may request records or documentation of participation in services. I will discuss the information and/or documentation with you in session prior to sending it to the court.
● Written Request: Clients must sign a release of information form before any information may be sent to a third party. A summary of visits may be given in lieu of actual “psychotherapy/process notes”, except if the third party is part of the medical team. If therapy sessions involve more than one person, each person over the age of 18 MUST sign the release of information before information is released.
● Fee Disputes: In the case of a credit card dispute, I reserve the right to provide the necessary documentation (i.e. your signature on the “Therapy Consent & Agreement” that covers the cancellation policy to your bank or Credit Card Company should a dispute of a charge occur. If there is a financial balance on account, a bill will be sent to the home address on the intake form unless otherwise noted.
● Couples Counseling & “No Secret” Policy: When working with couples, all laws of confidentiality exist. I request that neither partner attempt to triangulate me into keeping a “secret” that is detrimental to the couple's therapy goal. If one partner requests that I keep a “secret” in confidence, I may choose to end the therapeutic relationship and give referrals for other therapists as our work and your goals then become counter-productive. However, if one party requests a copy of couples or family therapy records in which they participated, an authorization from each participant (or their representatives and/or guardians) in the sessions before the records can be released.
● Dual Relationships & Public: Our relationship is strictly professional. In order to preserve this relationship, it is imperative that there is no relationship outside of the counseling relationship (i.e.: social, business, or friendship). If we run into each other in a public setting, I will not acknowledge you as this would jeopardize confidentiality. If you were to acknowledge me, your confidentiality could be at risk.
● Social Media: No friend requests on our personal social media outlets (Facebook, LinkedIn, Pinterest, Instagram, Twitter, etc.) will be accepted from current clients and possibly former clients. This denial is a reflection of ethical excellence and not a reflection of anything else. If you choose to comment on our professional social media pages or posts, you do so at your own risk and may breach confidentiality. I cannot be held liable if someone identifies you as a client. Posts and information on social media are meant to be educational and should not replace therapy. Please do not contact me through any social media site or platform. They are not confidential, nor are they monitored, and may become part of a medical record.
● Electronic Communication: If you need to contact me outside of our sessions, via phone is the safest means. Clients often use text or email as a convenient way to
communicate in their personal lives. However, texting introduces unique challenges into the therapist–client relationship. Texting is not a substitute for sessions. Texting can compromise confidentiality. Phones can be lost or stolen. DO NOT communicate sensitive information over text. The identity of the person texting is unknown as someone else may have possession of the client’s phone. If you choose to communicate by this means you do so at your own risk. Do not use email for emergencies. In the case of an emergency call 911, your local emergency hotline or go to the nearest emergency room. Additionally, e-mail is not a substitute for sessions. If you need to be seen, please call to book an appointment. Email can compromise confidentiality. Do not communicate sensitive medical or mental health information via email. Furthermore, if you send email from a work computer, your employer has the legal right to read it. E-mail is a part of your medical record. If you choose to communicate by this means you do so at your own risk.
● Attending a session under chemical influence: It is counter therapeutic to attend appointments under the influence. If your clinician discerns this has occurred, in their professional judgment, they may terminate your appointment early and you should expect to be financially responsible for the entire appointment.
PART III: REASONS SOME THERAPISTS DO NOT ACCEPT INSURANCE
● Reduced Ability to Choose: Most health care plans today (insurance, PPO, HMO, etc.) offer little coverage and/or reimbursement for mental health services. Most HMOs and PPOs require “preauthorization” before you can receive services. This means you must call the company and justify why you are seeking therapeutic services in order for you to receive reimbursement. The insurance representative, who may or may not be a mental health professional, will decide whether services will be allowed. If authorization is given, you are often restricted to seeing the providers on the insurance company’s list. Reimbursement is reduced if you choose someone who is not on the contracted list; consequently, your choice of providers is often significantly restricted.
● Pre-Authorization and Reduced Confidentiality: Insurance typically authorizes several therapy sessions at a time. When these sessions are finished, your therapist must justify the need for continued services. Sometimes additional sessions are not authorized, leading to an end of the therapeutic relationship even if therapeutic goals are not completely met. Your insurance company may require additional clinical information that is confidential in order to approve or justify a continuation of services. Confidentiality cannot be assured or guaranteed when an insurance company requires information to approve continued services.
Even if the therapist justifies the need for ongoing services, your insurance company may decline services. Your insurance company dictates if treatment will or will not be covered. Note: Personal information might be added to national medical information data banks regarding treatment.
● Negative Impacts of a Psychiatric Diagnosis: Insurance companies require clinicians to give a mental health diagnosis (i.e., “major depression” or “obsessive-compulsive disorder”) for reimbursement. Psychiatric diagnoses may negatively impact you in the following ways:
1. Denial of insurance when applying for disability or life insurance;
2. Company (mis)control of information when claims are processed;
3. Loss of confidentiality due to the increased number of persons handling claims;
4. Loss of employment and/or repercussions of a diagnosis in situations where you may be required to reveal a mental health disorder diagnosis on your record. This includes but is not limited to: applying for a job, financial aid, and/or concealed weapons permits.
5. A psychiatric diagnosis can be brought into a court case (ie: divorce court, family law, criminal, etc.).
It is also important to note that some psychiatric diagnoses are not eligible for reimbursement. This is often true for marriage/couples therapy.
Why Some Clinicians Do Not Take Insurance: These involve enhanced quality of care and other advantages:
1. You are in control of your care, including choosing your therapist, & length of care.
2. Increased privacy and confidentiality (except for limits of confidentiality).
3. Not having a mental health disorder diagnosis on your medical record.
4. Consulting with me on non-psychiatric issues that are important to you that aren’t billable by insurance, such as learning how to cope with life changes, gaining effective communication techniques for relationships, increasing insight, and developing new skills.
After reading this position on why I don’t accept health insurance, you still may decide to use your health insurance. I will do my best to recommend a therapist for you.
PART IV: CONSENT
Boundless Hope is defined as any and all agents, providers, subcontractors, and employees of Boundless Hope.
1. I have read and understand the information contained in the Therapy Agreement, Policies and Consent. I have discussed any questions that I have regarding this information with my provider. My signature below indicates that I am voluntarily giving my informed consent to receive counseling services and agree to abide by the agreement and policies listed in this consent. I authorize Boundless Hope to provide counseling services that are considered necessary and advisable.
2. I authorize the release of treatment and diagnosis information if I am requesting insurance reimbursement as necessary to process superbills for services to my insurance company. I acknowledge that I am financially responsible for payment and it is my responsibility to verify whether counseling is an eligible expense for reimbursement.
3. Insurance Fee Estimation and Payments: I understand that the insurance estimates provided are not a guarantee of coverage, and that I am responsible for any costs not covered or denied by my insurance. It is not uncommon for the estimate provided by insurance companies that is given at the verification of benefits provided by insurance clearing houses and/or the insurance provider itself, to be inaccurate. Boundless Hope has no control over this inaccuracy. In the event that the required fee for the session changes once a claim is processed, clients will be charged/refunded the difference.
4. I understand that some providers at Boundless Hope do not bill or process insurance benefits as some providers are fee for service only.
5. If there were to be a complete denial of claims submitted for therapy services that were already rendered, the client will take full financial responsibility for those services at that provider's full fee private pay rate. As a client wishing to access any of their insurance benefits, the client takes full financial responsibility should their insurance company deny or change their benefits.
6. It is the client’s full responsibility to accurately report current up to date primary insurance coverage to the administrative staff and are encouraged to independently verify eligibility of benefits.
Part V. Self-Pay Rates and Contracted Rates: A Client’s Right to Choose
1. I understand that if I choose to use an eligible insurance plan for services, I may have to pay a fee for services that is different from the full contracted amount and that this amount may differ from the therapist’s self-pay rate as shown in the Good Faith Estimate.
2. I understand that if I choose to self pay for therapy services, and not use my insurance plan, I will pay the clinician’s self pay rate, which may differ from the insurance contracted rate and/or the rate accessed through my insurance policy. If I choose to self-pay for services, these payments will not count towards my annual insurance deductible or out-of-pocket maximum. I am voluntarily signing this document that I have read and understand the above and it is my financial responsibility to pay in full whatever my insurance doesn’t cover. I certify that I have chosen, of my own volition, to access or not access any applicable insurance benefits.
Part VI. Late Cancellations and No Shows for Insurance Clients
Should I decide to use insurance for my visits, I understand that Boundless Hope cannot legally charge my insurance company for missed or late canceled appointments. I understand that I will owe the clinician’s full self-pay rate, not my insurance rate for any late-canceled (canceled within 24 hours of the appointment time) or missed (no show) appointments.