Initial Paperwork

Thank you for choosing Heart Matters Therapy, PLLC for your counseling and therapy needs. This document contains important information about our professional services, business policies, and how we're going to work together. Please read this entire document carefully and feel free to discuss with us any questions that you may have.

The counseling process is a confidential process designed to help you address your concerns, come to a greater understanding of yourself, and learn effective personal and interpersonal coping strategies. It involves a relationship between you and a trained therapist who has the desire and willingness to help you accomplish your individual, family, or relationship goals. The outcome of counseling is often positive; however, the level of satisfaction varies for each individual.

Counseling can have both benefits and risks. While counseling can be of benefit to most people, the counseling process is not always easy. It involves sharing sensitive, personal, and private information that may, at times, be distressing and increase anxiety or confusion. It is important that you and your therapist discuss any discomfort you experience. Your therapist may be able to help you understand the experience and/or use different methods or techniques to ease the discomfort.

Working together with a therapist is a professional relationship rather than a social one. Please do not invite any of our therapists to social gatherings, offer them gifts, or ask them to write references for you. You will be best served if our sessions concentrate exclusively on your concerns.

An initial evaluation is conducted before any therapeutic sessions can begin. During this evaluation, both you (the client) and the therapist will determine if your therapist is the best person to help you reach your goal(s). Therapy sessions are usually 50-60 minutes long and are scheduled according to an agreement between you (the client) and your therapist. Please notify your therapist if you are unable to attend any session that you have scheduled.

The law protects the privacy of all communications between a client and a therapist. In most situations, we can release information about your treatment to others only if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. However, there are several exceptions as indicated below:

1. If it is believed that a client is potentially harmful to himself or herself or to someone else, confidentiality may be broken in order to protect you or someone else from imminent danger. The law also requires that potential harm towards others, including threats of harming someone, be reported to the potential victim, as well as to the police or other necessary professionals.

2. If we have reasonable knowledge of or suspect physical or sexual abuse or neglect of a child under 18, we must file a report with the Crimes Against Children Division of Arkansas State Police.

3. If a court of law issues a subpoena or other court order, Heart Matters Therapy, PLLC may be required to provide the information specified by the subpoena or court order.

4. There may be occasions when your therapist may find it helpful to consult with another professional about your treatment. Consultations occur in a private location with another professional who is also bound by the same confidentiality laws.

5. Insurance companies often require information about your treatment for benefit determination and payment. Such information can include diagnosis, treatment plan, and progress notes. Please contact your insurance carrier if you have questions about its privacy practices.

**Please ensure that you have read and understood your Protected Health Information Rights as set forth in the Heart Matters Therapy, PLLC's Notice of Privacy Practices.**

You should be aware that, pursuant to HIPAA, we 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 we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive 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.

Except in unusual circumstances where disclosure would physically endanger you and/or others or refers to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, 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, we recommend that you initially review them in the presence of your therapist or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, we are allowed to charge a copying fee of $1 per page. If we refuse your request for access to your Clinical Records, you have a right of review (except for information supplied to us confidentially by others), which we will discuss with you upon request.

In addition, we also keep Psychotherapy Notes. These Notes are for our own use and are designed to assist us in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations with your therapist, our analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal that is not required to be included in your Clinical Record. They also include information from others provided to me confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies, without your written, signed authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Records 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you.

Clients under 18 years of age (who are not emancipated) and their parents should be aware that the law may allow parents to examine their child's treatment records. They should also be aware that clients over 14 years of age can consent to (and control access to information about) their own treatment. While privacy in therapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually our policy to request an agreement from any client aged 14-18 and their parents, allowing us to share general information with parents about the progress of treatment and the child's attendance at scheduled sessions. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he or she may have.

Heart Matters Therapy, PLLC is NOT a party to your divorce decree. Adult clients are responsible for their bill at the time of service. The responsibility to pay for services to minor children rests with the accompanying adult. If the divorced couple is splitting costs, one person must take responsibility for bringing the child to their appointments, payment of services, keeping track of payments, and other documentation related to the services provided.

It is the policy of Heart Matters Therapy, PLLC to attempt to obtain consent for services from all legal custodial parents/guardians. Information about your child's legal custodial parents/guardians will be obtained at your initial appointment. After this appointment, your child's therapist will attempt to contact all legal custodial parents/guardians to assure that they are aware that the child is in therapy and that they consent to services. All legal custodial parents/guardians will also be invited to participate in your child's therapy services when therapeutically appropriate. If your child's therapist is unable to reach a legal custodial parent/guardian this will be documented in your child's electronic health record and Heart Matters Therapy, PLLC will continue to provide services to your child. If any legal custodial parent/guardian refuses to consent for services for your child then Heart Matters Therapy, PLLC will not be able to continue services with your child.

There is only one assigned Guarantor on record for a client. Thus, one person will be the assigned person who guarantees Heart Matters Therapy, PLLC will receive payment for services. This is the person who will be expected to render payment. If payment for services is to be divided between parents, the parents will need to make that arrangement. Heart Matters Therapy, PLLC will only bill one person, and the person bringing the child to the appointment will be expected to pay.

Therapists at Heart Matters Therapy, PLLC are not able to make any visitation, custody, or contact recommendations for your child. We provide outpatient therapeutic services and any recommendations made from therapy are purely therapeutic recommendations.

Any legal custodian/parent/guardian of your child will be allowed access to your child's appointment history, electronic health record, any other related treatment information should they request it.

The hourly fee varies for the type of service provided by our therapists. Session fees for Individuals are as follows: Intake Assessment ($150) and Individual Sessions ($125). Session fees for Couples and Families are as follows: Intake Assessment ($200) and Couples or Family Sessions ($150). Sliding scale fees are available and based upon your income. Sliding scale fees can range from $90-$150 per session. Session fees for groups will be $50 per participant per session. Full payment for services will need to be made before the start of your session through IvyPay.

1. The first copy of a client's medical record will be provided to the guardian or to a party specified by the guardian at no charge. All subsequent copies will be charged $1.00 per page with a minimum charge of $5.00.

2. If a client submits paperwork to Heart Matters Therapy, PLLC to be completed and returned to a third party such as attorneys, medical providers, employers, social workers, schools, and the court system, we will charge an hourly rate of $125.00 per hour, with a minimum fee of $250.

3. Certified records will be provided to requesting parties as dated by the court order or within 30 days of the request; whichever date comes sooner. Heart Matters Therapy, PLLC charges $50.00 per certified record. The amount must be paid at the time of the request unless agreed otherwise by a managing partner at Heart Matters Therapy, PLLC. If records are needed in less than 30 days but more than 10 days there is an additional rush charge of $15.00. If records are needed in less than 10 days there is an additional rush charge of $30.00.

4. If a Heart Matters Therapy, PLLC therapist is subpoenaed for court, depositions, trial, or any other proceeding requiring personal attendance, the client will be billed at a rate of $125.00 per hour with a minimum of 4 hours. In the event that the therapist's attendance requires less than 4 hours, the minimum fee will still apply and will be nonrefundable. There will also be a mileage fee charged at the standard federal rate.

When an appointment has been scheduled, that time has been reserved only for you. If you discover that you are unable to keep a scheduled appointment, please call us at (501) 588-7877 to cancel as soon as possible. If you need to cancel or reschedule your appointment, you must provide a 48-hour advance notice to prevent being charged. Clients that miss or cancel appointments with less than a 48-hour notice (and there is not a verifiable emergency or illness) will be billed the full session fee.

Please note that because your time slot has been reserved just for you, every effort is made to start and end on time. It is important to arrive on time or to call if you are running late. We allow a 10-minute grace period if you are running late. After the 10-minute grace period, you will be considered a "no show" client, your session will be canceled, and you will be charged the full session fee. After two (2) no-show appointments, you may be terminated from all counseling services by your therapist.

At this time, Heart Matters Therapy, PLLC is considered an "out of network provider", meaning we do not bill insurance for any of the services that we provide. As a result, you are entitled to a Good Faith Estimate of the cost of services you are seeking. Good Faith Estimates are available upon request. Effective January 1, 2022, we will only provide superbills to those wishing to seek reimbursement from their insurance provider. You must check with your insurance provider to determine if you are eligible to receive reimbursement for services. Please let your therapist know as soon as possible if you would like to discuss this arrangement.

Our session rates are in effect at the time that the client signs this Service Agreement; however, nothing in this agreement precludes Heart Matters Therapy, PLLC from periodically changing its rates for service. Although the above quoted fees are in effect as a base rate for all clients (please refer to 'Professional Fees' section), Heart Matters Therapy, PLLC may charge individual clients according to a Sliding Fee Scale based on the client's income. Acceptable forms of payment include major credit cards (VISA, Mastercard, Discover, American Express), HSA, and FSA accounts. You will be expected to pay for each session at the time it is held, via IvyPay, unless we agree otherwise. In circumstances of financial hardship, we may be willing to negotiate a fee adjustment or payment plan.

If a credit card transaction is declined, Heart Matters Therapy, PLLC will reverse the payment amount and add a $25.00 service fee to cover our costs.

During regular business hours, we strive to have our phones answered promptly. If a therapist is not seeing a client, he or she will do everything possible to take the call. If the therapist is not available, please leave a detailed voice message, and your call will be returned as soon as possible.

At this time, we are unable to provide on-call or after-hours services. If you need to contact your therapist after business hours, please leave a message on the voice mail and your call will be returned the next business day. In the event of an emergency, you should call 911 or a local Hospital or Crisis Center.

While it may be easy to search and find our therapists on Facebook, Instagram, Twitter, Linkedln and other social networking sites, please note that your therapist will not accept any requests from current or former clients on these platforms. We believe that adding current or former clients on these platforms impacts our professional relationship with you (the client) and poses a risk to your privacy. Please do not take it personal if your therapist does not add you as a friend or denies your request to follow them on these social media platforms. We want to continue to uphold the standard of professionalism and respect the therapist-client relationship.

If you choose to e-mail us, please note that your e-mail, as well as our response, may not be secure. As with any form of e-mail communication, confidentiality may be breached. Please use e-mail with discretion.

Any harassing communications, including offensive or abusive language, will not be tolerated whether by telephonic or electronic communication. If a client engages in such behavior, he or she will be asked to leave the session, to disconnect from the telephone and resume at a later date/time, and/or be asked not to contact our office via email. If this behavior persists and the offending party does not comply with requests to stop, Heart Matters Therapy, PLLC reserves the right to call the police or other appropriate law enforcement authority.

Any and all Heart Matters Therapy, PLLC's therapists and counselors reserve the right to postpone or terminate counseling for clients who attend sessions while under the influence of drugs and/or alcohol.

By signing below, you indicate that:

1. You have read, understood, and agreed to these terms.

2. You are the client and authorized to sign this agreement and accept these terms.

 

You should retain a copy of this document for your records.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of protected health information, this information may include notes from your health care provider, your medical history, your test results, treatment notes and insurance information. We are also required to provide individuals with notice of our legal duties and privacy practices in regard to protected health information, and to notify affected individuals about breach of unsecured protected health information. This notice describes how we may use and disclose your medical information. It also describes your rights and our legal obligations with respect to your medical information. If you have any questions about this Notice, please contact our Privacy Officer at 501-588-7877.

 1. Treatment. We use medical information about you to provide you with our services or treatment and we may share your medical information with other providers involved in your care. For example, we may share your treatment results with your doctor, etc.

2. Payment. We use and disclose medical information about you to obtain payment for the services we provide. For example, we give your health plan the information it requires before it will pay us. We may also disclose information to other health care providers to assist them in obtaining payment for services they have provided to you.

3. Health Care Operations. We may use and disclose medical information about you to operate this practice. For example, we may use and disclose this information to review and improve the quality of services we provide or check on performance of our staff. Or we may use and disclose this information to get your health plan to authorize services or referrals. We may also use and disclose this information as necessary for medical reviews, legal services, and audits, including fraud and abuse detection and compliance programs. We may also share your medical information with our "business associates," such as our billing service, that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your protected health information. We may also share your information with other health care providers, health care clearinghouses or health plans that have a relationship with you.

4. Appointment Reminders. We may use and disclose medical information to contact and remind you about appointments. Reminders may be sent in the mail, by email, or by phone call or voicemail message. If you do not wish to get reminders, please let us know. If you are not home, we may leave this information on your answering machine or in a message left with the person answering the phone.

5. Sign-in Sheet. We may use and disclose medical information about you by having you sign in when you arrive at our office. We may also call out your name when we are ready to see you.

6. Required by Law. As required by law, we will use and disclose your health information, but we will limit our use or disclosure to the relevant requirements of the law. When the law requires us to report abuse, neglect or domestic violence, or respond to judicial or administrative proceedings, or to law enforcement officials, we will further comply with the requirement set forth below concerning

7. Public Health. As required by law, we may disclose your health information to public health authorities for purposes related to preventing or controlling disease, injury or disability; reporting child, elder or dependent adult abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

8. Health Oversight Activities. We may, and are sometimes required by law, to disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure, and other proceedings, subject to the limitations imposed by law.

9. Judicial and Administrative Proceedings. We may, and are sometimes required by law, to disclose your health information in the course of any administrative or judicial proceeding to the extent expressly authorized by a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process if reasonable efforts have been made to notify you of the request and you have not objected, or if your objections have been resolved by a court or administrative order.

10. Law Enforcement. We may, and are sometimes required by law, to disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order, warrant, grand jury subpoena and other law enforcement purposes.

11. Public Safety. We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

12. Specialized Government Functions. We may disclose your health information for military or national security purposes or to correctional institutions or law enforcement officers that have you in their lawful custody.

13. Workers' Compensation. We may disclose your health information as necessary to comply with workers' compensation laws. For example, to the extent your care is covered by workers' compensation, we will make periodic reports to your employer about your condition. We are also required by law to report cases of occupational injury or occupational illness to the employer or workers' compensation insurer.

14. Change of Ownership. In the event that this medical practice is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to practice or provider.

15. Breach Notification. In the case of a breach of unsecured protected health information, we will notify you as required by law. If you have provided us with a current e-mail address, we may use e-mail to communicate information related to the breach. In some circumstances our business associate may provide the notification. We may also provide notification by other methods as appropriate.

16. Psychotherapy Notes. We will not use or disclose your psychotherapy notes without your prior written authorization except for the following: 1) use by the originator of the notes for your treatment, 2) for training our staff, students and other trainees, 3) to defend ourselves if you sue us or bring some other legal proceeding, 4) if the law requires us to disclose the information to you or the Secretary of HHS or for some other reason, 5) in response to health oversight activities concerning your psychotherapist, 6) to avert a serious and imminent threat to health or safety, or 7) to the coroner or medical examiner after you die. To the extent you revoke an authorization to use or disclose your psychotherapy notes, we will stop using or disclosing these notes.

1. Right to Request Special Privacy Protections. You can request us not to use or share your information for treatment, payment, or health care operations. You can also ask us not to share information with individuals involved in your care (family members or friends You must make these requests in writing. We must share information when required by law. We reserve the right to accept or reject any other request and will notify you of our decision.

2. Right to Request Confidential Communications. You can request that you receive your health information in a specific way or at a specific location. For example, you may ask that we send information to a particular e-mail account or to your work address. You must make these requests in writing.

3. Right to Inspect and Copy. You have the right to see your health information and request a copy of that information with limited exceptions. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format.

4. Right to Amend or Supplement. You have a right to request that we amend or change your health information that you believe is incorrect or incomplete. You must make such requests in writing and provide a reason for the change. We don't have to change your health information and will provide you with information about this practice's denial and how you can disagree with the denial. We may deny your request if we do not have the information, if we did not create the information (unless the person or entity that created the information is no longer available to make the amendment), if you would not be permitted to inspect or copy the information at issue, or if the information is accurate and complete as is. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal. All information related to any request to amend will be maintained and disclosed in conjunction with any subsequent disclosure of the disputed information.

5. Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information made by this practice. You must make such request in writing. This practice does not have to account for the disclosures provided to you or pursuant to your written authorization, or as described in above paragraphs: (treatment), (payment), (health care operations), (notification and communication with family) and (specialized government functions) of Section A of this Notice of Privacy Practices or disclosures for purposes of research or public health.

6. Right to a Paper or Electronic Copy of this Notice. You have a right to notice of our legal duties and privacy practices with respect to your health information, including a right to a paper copy of this Notice of Privacy Practices, even if you have previously requested its receipt by e-mail.

We reserve the right to change this Notice of Privacy Practices at any time in the future. After an amendment is made, the revised Notice of Privacy Protections will apply to all protected health information that we maintain, regardless of when it was created or received. We will keep a copy of the current notice posted in our practice location, and a copy will be available at each appointment.

You can file a complaint with us or with the government if you think that your information was used or shared in a way that is not allowed. You can also complaint when you were not allowed to view a copy of your information. To file a complaint with us, please contact our Privacy Officer listed at the top of this form. You can file a complaint with your regional office of the United States Office of Civil Rights. You will not be penalized in any way for filing a complaint.

By signing below, you indicate that:

1. You have read and understood the Privacy Policies disclosed in this notice.

2. You are the client and authorized to sign this agreement and accept these terms.

 

You should retain a copy of this document for your records.

This informed consent document is intended to provide general information about the counseling services provided by Heart Matters Therapy, PLLC. This is a legal document; please read it carefully before signing.

1. I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below only indicates that I have read this agreement.

2. I understand that I can discuss my concerns with you, the therapist, before I start formal therapy. If at any time during the treatment I have questions or concerns, I can talk with you about them and you will do your best to answer them.

3. I understand that after therapy begins, I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy.

4. I understand that no specific promises have been made by Heart Matters Therapy, PLLC or this therapist about the results of treatment, the effectiveness of the treatments used by this therapist, or the number of sessions necessary for therapy to be effective.

5. I have read and understand the information provided above regarding therapy, have discussed it with my health care provider and all of my questions have been answered to my satisfaction.

1. I understand that telehealth or teletherapy involves the use of electronic information and communication technologies by a health care provider to deliver services to an individual when he or she is located at a different site than the provider; and hereby consent to receiving healthcare services to me via telehealth over secure video conferencing platform.

2. I understand that the laws that protect privacy and the confidentiality of my medical information also apply to telehealth or teletherapy.

3. I understand that while telehealth or teletherapy treatment has been found to be effective in treating a wide range of disorders, there is no guarantee that all treatment of all clients will be effective.

4. I understand that there are potential risks involving technology, including but not limited to: Internet interruptions, and technical difficulties. I understand that technical difficulties with hardware, software, and internet connection may result in service interruption and that the health care provider is not responsible for any technical problems and does not guarantee that services will be available or work as expected.

5. I understand that I am responsible for information security on my computer and in my own physical location. I understand that I am responsible for creating and maintaining my username and password and not share these with another person. I understand that I am responsible to ensure privacy at my own location by being in a private location so other individuals cannot hear my conversation.

6. I understand that my healthcare provider or I can discontinue the telehealth/teletherapy services if it is felt that this type of service delivery does not benefit my needs.

By signing below, you indicate that:

1. You have read and understood the information provided above regarding telehealth or teletherapy.

2. You have discussed it with your health care provider and all of your questions have been answered to your satisfaction.

3. You give your informed consent for the use of telehealth or teletherapy in your care.

 

You should retain a copy of this document for your records.

No form of communication is considered to be 100% secure. As such, Heart Matters Therapy, PLLC cannot guarantee attempts to access, use, or disclose personal information exchanged electronically--including text messages and email. Additionally, these forms of communication are not compliant with HIPAA, unless otherwise noted with a signed BAA.

We understand that as technology advances, it is easier for our clients to utilize these forms of electronic communication. You may elect to communicate with us via text message or email regarding scheduling and administrative issues. If you opt to utilize electronic forms of communication, please be aware that your therapist is ethically and legally obligated to maintain a record of all forms of communication (phone, email, text), which can be subpoenaed by a judge as part of a client's file/record. No form of electronic communication should be used to discuss therapeutic content or to request assistance in emergency situations.

By signing below, I indicate that I have read, understood, and agreed to receive the electronic communication of my choice, as selected above. I also agree that this agreement can be revoked, at any time, by myself or my counselor with written notice.

In an effort to better serve clients and simplify the billing experience, Heart Matters Therapy, PLLC offers electronic payment options, enabling you to pay for sessions with a credit card, debit card, Health Savings account, or Flexible Spending account. Your information is secure. No one, including your therapist, will ever see or have access to your account information.

All sensitive, confidential information is managed and seen by you only. Ivy Pay was designed to uniquely support the therapeutic relationship. Among the ways that small business can accept credit cards, Ivy Pay is the only way to protect client privacy under HIPAA and hold the therapeutic relationship in confidence.

Ivy Pay is designed specifically for therapists and their clients and is fully HIPAA compliant. Charges will appear as Ivy transactions. There is no surcharge for paying electronically and transaction fees are not passed on to you as the client.

In the event that you miss an appointment or fail to cancel an appointment within 48 hours of the scheduled time, you will be charged the full session fee.

By signing this form, you agree to:

1. Authorize Heart Matters Therapy, PLLC's use of Ivy Pay to process your credit, debit, FSA or HSA card.

2. Authorize Heart Matters Therapy, PLLC to charge your credit, debit, FSA or HSA card via Ivy Pay in the amount of your agreed upon session fee.

3. Authorize Heart Matters Therapy, PLLC to charge for sessions, either attended or missed, as detailed above.

4. Accept all charges without disputing them ("charge back") for sessions you have received or appointments you have missed, according to the above policy.

 

You should retain a copy of this document for your records.