1. SERVICES. Client acknowledges that he/she will be utilizing the professional services of BCS, and that some of the items below may not necessarily apply to such services.
From time to time during the term of this Agreement, Client may request that BCS provide certain counseling services to Client via telephone and video conferencing technology (the "
Client acknowledges and agrees that Client is solely responsible to ensure that the environment where Client is located during any online counseling session is sufficiently private as to ensure that no personal or confidential information is relayed to any third party other than the BCS professional. At no time will BCS be responsible for i) any information that is disclosed or ii) any other damages suffered by Client due to the condition or location of the environment where Client is located during any counseling session. Client shall be responsible for the full cost of the applicable session if any interruption or stoppage occurs due to Client's action or the environment where Client is located, including without limitation weather and equipment failure.
Client acknowledges and agrees that the Services are not a substitute for assistance or help required in an emergency or crisis situation. As such, Client agrees that any such emergency or crisis situation will be handled by the appropriate emergency personnel by calling the appropriate emergency response telephone number, including without limitation dialing 9-1-1. At no time will BCS be repsonsible for any costs for emergency or crisis assistance.
Client acknowledges and agrees that Client is solely responsible for any personal injury Client may suffer due to any phyiscal activity in which Client engages during the provision of the Services.
2. PAYMENT FOR SERVICES.
(a) Client acknowledges and agrees that the total amounts charged hereunder are due when the services are rendered. Client agrees that the rates for the Services are told to the client by a representative of BCS before services are rendered. Client shall provide a current, valid credit card with sufficient credit to provide payment to BCS.
(b) In consideration of court attendance, Client agrees to pay BCS the rate of two hundred dollars ($200.00) per hour for any court attendance. Client agrees that the hourly rate begins when the professional leaves the applicable location. Client agrees that a minimum fee representing two (2) hours of court attendance ($500.00) shall be paid prior to any such court attendance and is non-refundable even if less than two (2) hours is expended by the professional. If the court attendance exceeds two (2) hours, Client agrees that BCS may charge Client's credit card for the additional time. In addition, Client understands and agrees that Client is not paying for specific testimony from the applicable professional, but for the professional's time. Therefore, such fees must be paid regardless of the professional's testimony or whether the professional actually testifies or not. Further, Client is financially responsible for missed appointments.
As such, Client agrees that if Client does not provide at least twenty-four (24) hours' notice of any cancellation, BCS may charge Client's credit card a fee of seventy-five dollars ($75.00) as payment for BCS's reasonable estimation of the damages caused by Client's cancellation. All cancellations must be received via telephone call.
(c) In addition, if you are submitting bills to your insurance provider for out-of-network coverage for the Services, upon request BCS will provide Client with a superbill for all services provided to Client. It is Client's responsibilty to submit the superbill to the applicable insurance carrier.
(d) Client agrees and understands that Client is financially responsible for all the charges incurred by Client not adressed by this Agreement. Any payments not received within the timeframe set forth herein shall be subject to an interest charge of one and one half percent (1.5%) per month. Further, should BCS utilize the services of an attorney or law firm to collect any overdue balances, Client shall pay BCS all attorneys' fees and expenses associated with collecting the same.
(e) Client shall call our office at (240)-986-1001 prior to first appointment to provide credit card information to be kept on file.
3. RELATIONSHIP OF PARTIES. The parties hereto are independent contractors. Nothing in this Agreement shall be deemed to create any form of partnership, principal-agent relationship, employer-employee relationship, or joint venture between the parties hereto.
4. CONFIDENTIAL AND PROPRIETARY INFORMATION. For purposes of this Agreement, "Confidential Information" means all non-public information and trade secrets disclosed to Client, as well as the confidential and valuable information BCS desires to protect against disclosure and which is disclosed in writing, oral communication or electronic means, and is marked "confidential" or "proprietary" or with a designation of similar meaning. During the term of this Agreement, and indefinitely thereafter, Client agrees not to sell, license, transfer, publish, disclose, display or otherwise make available to others, or to use any Confidential Information in connection except for the purposes of the Agreement and shall only disclose Confidential in connection with this Agreement. Client shall not make, or permit to be made, any copies of Confidential information, except in connection with this Agreement.
5. INDEMNIFICATION. Client agrees to indemnify, defend and hold BCS and its members, managers, officers, employees, contractors, representatives and agents harmless from and against all claims, losses, expenses, fees (including attorneys' fees), costs, and judgements that may be asserted against BCS or its members, managers, officers, employees, contractors, representatives and agents due to i) Client's breach of any provision of this Agreement and ii) Client's wrongful acts and omissions.
6. LIMITED WARRANTY. EXCEPT AS EXPRESSLY SET FORTH HEREIN, BCS EXPRESSLY DISCLAIMS ANY AND ALL WARRANTIES, EXPRESS OR IMPLIED, ORAL OR WRITTEN, WITH RESPECT TO THE SERVICES AND THE PROFESSIONALS PROVIDING THE SERVICES INCLUDING, WITHOUT LIMITATION, ALL IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR ANY PARTICULAR PURPOSE AND NO REPRESENTATIVE OF BCS IS AUTHORIZED TO GIVE ANY ADDITIONAL WARRANTY.
7. ENTIRE AGREEMENT. This Agreement contains the entire agreement of the parties, and there are no other promises or conditions in any other agreement whether oral or written.
8. SEVERABILITY. If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If a court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited.
9. LIMITATION OF LIABILITY. IN NO EVENT WILL BCS HAVE ANY LIABILITY OR RESPONSIBILITY FOR ANY INDIRECT, INCIDENTAL, EXEMPLARY, SPECIAL OR CONSEQUENTIAL DAMAGES, EVEN IF ADVISED OF THE POSSIBILITY OF SUCH DAMAGES.
10. TECHNOLOGY. BY SIGNING THE BOTTOM OF THIS FORM YOU UNDERSTAND, AGREE TO, AND ARE GIVING US PERMISSION TO USE THE FOLLOWING TECHNOLOGY.
(a) Cell Phones: In addition to landlines, cell phones may not be completely secure or confidential. There is also a possibility that someone could overhear or intercept your conversations. Be aware that individuals who have access to your cell phone or cell phone bill may be able to see who you have talked to, who initiated that call, how long the conversation was, and where each party was located when that call occurred. However, I realize that most people have and utilize a cell phone. I may also use a cell phone to contact you, typically only regarding setting up an appointment if needed. Telephone conversations (other than just setting up appointments) are billed at my hourly rate. Additionally, I keep your phone number in my cell phone, but it is listed by your initials only and my phone is password protected. if this is a problem, please let me know, and we will discuss our options.
(b) Text Messaging: Text messaging is not a secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to text because it is a quick way to convert information. Nonetheless, please know that it is my policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via text to prevent compromising your confidentiality. You also need to know that I am required to keep a copy or summary of all texts as part of your clinical record that address anything related to therapy.
(c) Email: Email is not a secure means of communication and may compromise your confidentiality. However, I realize that many people prefer to email because it is a quick way to convert information. Nonetheless, please know that it is my policy to utilize this means of communication strictly for appointment confirmations. Please do not bring up any therapeutic content via email to prevent compromising your confidentiality. You also need to know that I am required to keep a copy or summary of all emails as part of your clinical record that address anything related to therapy. I also strongly suggest that you only communicate through a device that you know is safe and technologically secure (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.). If you are in a crisis, please do not communicate this to me via email because I may not see it in a timely manner. Instead, please see below under "Emergency Procedures".
(d) Social Media- Facebook, Twitter, LinkedIn, Instagram, Pinterest, Etc: It is my policy not to accept "friend" or "connection" requests from any current or former client on my personal social networking sites such as Facebook, Twitter, Instagram, Pinterest, etc. because it may compromise your confidentiality and blur the boundries of our relationship. Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have insuffcient security, and I do not watch them closely. I would not want to miss an important message from you.
(e) Video Conferencing (VC): Video Conferencing is an option for us to conduct remote sessions over the internet where we not only can speak to one another, but we may see each other on a screen. I utilize Go To Meeting. At the present time Skype is NOT willing to sign a BAA and it is not recommended. This VC platform is encrypted to the federal standard, HIPAA compatible, and has signed a HIPAA Business Associate Agreement (BAA). The BAA means that Go To Meeting is willing to attest to HIPAA compliance and assumes responsibilty for keeping our VC interaction secure and confidential. If we choose to utilize this technology, I will give you detailed directions regarding how to log-in securely. I also ask that you please sign on to the platform at LEAST five minutes prior to your session time to ensure we get started promptly. Additionally, you are responsible for initiating the connection with me at the time of the appointment. I strongly suggest that you only communicate through a computer or device that you know is safe ( e.g. has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.)
(f) Faxing Medical Records: If you authorize me (in writing) via a "Release of Information" form to send your medical records or any form of PHI to another entity for any reason, I may need to fax that information to the authorized entity. It is my responsibility to let you know that fax machines may not be a secure form of transmitting information. Additionally, information that has been faxed may also remain in the hard drive of my fax machine. However, my fax machine is kept behind two locks in my office. And, when my fax machine needs to be replaced, I will destroy the hard drive in a manner that makes future access to information on the device inacessible.
(g) Recommendations to Websites or Applications (Apps): During the course of our treatment, I may recommend that you visit certain websites for pertinent information or self-help. I may also recommend certain apps that could be of assistance to you and enhance your treatment. Please be aware that websites and apps may have tracking devices that allow automated software or other entities to know that you've visited these sites or applications. They may even utilize your information to attempt to sell you other products. Additionally, anyone who has access to the device you used to visit these sites/apps, may be able to see that you have been to these sites by viewing the history on your device. Therefore, it is your responsibility to decide if you would like this information as adjunct to your treatment or if you prefer that I do not make these recommendations. Please make me aware of your decision.
11. MISCELLANEOUS. This Agreement shall be binding upon and inure to the benefit of the parties and their respective successors, heirs, and permitted assigns. This Agreement may not be amended or modified except in a writing signed by both parties. This Agreement may not be assigned by either party without the express written consent of the other, which assignment without such written consent shall be void. This Agreement may be executed in one or more counterparts, each of which shall be deemed to be an original, but all of which together shall constitute one and the same document. Any facsimile, telecopy, email of a PDF file or similar electronic conveyance of an original signature shall be deemed an orginal signature and bind the parties. This Agreement shall be governed and construed under the laws of the State of Maryland without reference to its conflict of law principles. Neither party shall be liable for delays caused by fire, accident, labor dispute, war, insurrection, riot, act of government, act of God, or any other cause reasonably beyond its control, but each party shall use all reasonable efforts to minimize the extent of any such delay.
IN WITNESS WHEREOF, the parties hereto have duly executed and delivered Agreement as of the Effective Date.