Patient Agreement & Informed Consent
Welcome to Urban Counseling Collective (UCC)! This document (the Agreement) contains important information about our 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 we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail, and our practice is in general accordance with HIPAA policies. The law requires that we obtain your signature acknowledging that we have provided you with this information.
PLEASE NOTE: URBAN COUNSELING COLLECTIVE RESERVES THE EXCLUSIVE RIGHT TO ACCEPT OR DENY YOU AS A NEW PATIENT AND THAT ACCEPTANCE OR DENIAL OF NEW PATIENT STATUS WILL ONLY BE COMMUNICATED ONCE WE REVIEW THE INFORMATION YOU PROVIDED IN THIS ELECTRONIC DOCUMENT.
This document includes:
• Patient Agreement and Informed Consent
• Financial Policy
• Notice of Privacy Practices
• Social Media Policy
• Video Telehealth Patient Informed Consent Agreement
*These documents are also available individually on our website: www.urbancounselingcollective.com
Please note: If you are seeking couples counseling, the treatment of a child/family, psychological assessment, or medication management services, additional informed consent will be required.
The therapeutic relationship is unique in that it is a highly personal and at the same time, a professional and contractual agreement. Given this, it is important for the patient and clinician to reach a clear understanding about how their relationship will work, and what everyone can expect. This agreement and consent will provide a clear framework for the work you and your clinician will engage in. Feel free to discuss any of this with your clinician. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
MENTAL HEALTH SERVICES
Therapy is a relationship between people that works in part because of the clearly defined rights and responsibilities held by each person. Our goal is to create a safe space where you will be supported and empowered to create change. As a patient in psychotherapy and/or psychiatry, you have certain rights and responsibilities that are important for you to know about. There are also legal limitations to those rights. We, as your clinician(s), have corresponding responsibilities to you.
Patient Rights & Risks of Therapy:
A. You will be given a clear description from your clinician regarding the problems, diagnosis, and treatment interventions proposed.
B. Your participation in mental health treatment is voluntary and you may end treatment at any time. Although you are encouraged to discuss any reasons for ending therapy with your clinician, you reserve the right to stop treatment without any moral, legal, or financial obligations other than those already incurred. It is typically a good idea to complete therapy in a final service conclusion session. Further, your clinician may make diagnostic and treatment recommendations with which you do not agree but are professionally determined with your quality of care in mind. If these concerns ever arise, you are encouraged to discuss them with your clinician.
C. Your clinician cannot guarantee results of mental health services. However, any reasons, goals, and objectives for continuing or discontinuing mental health treatment will be clearly stated.
D. There may be some risks associated with participation in mental health services. These may include, but are not limited to, experiencing periods of emotional discomfort that arise during the course of treatment; being challenged or confronted on a particular issue; experiencing changes in relationships; or a worsening of symptoms before improvement is made. If this occurs, we recommend that you continue with therapy, as this is often part of the process of healing. These are normal aspects of the therapy process, and there is no guarantee about what you will experience. We will discuss your experience as we progress. If you or your clinician feels that the therapy is unhelpful with these specific issues, we will provide you with a referral for an alternative qualified professional.
If you have a grievance with your clinician or other employee of UCC, you are asked to first attempt to resolve this grievance directly with your clinician. In the event that the grievance is not satisfactorily resolved, please fill out a grievance form available at the front desk or https://www.urbancounselingcollective.com/wp-content/uploads/2022/04/Compliment-Grievance.pdf and give it to the front desk or email it to email@example.com
Our first 1-2 sessions will serve as an initial evaluation of your concerns, history, goals, and needs. At the end of this time period, your clinician will provide you with their impressions about how treatment may proceed based on what we feel will be of use for you in therapy. You should consider this, along with your own impressions and comfort with your clinician, when deciding if you are interested in proceeding with therapy together. Therapy requires a significant commitment of time, money, and energy, so you should choose your clinician carefully. If you find that your clinician is not a good fit for you, please speak with them or let administration staff know immediately so that we can find a better fit. It is especially important that you believe that your clinician is right for you; it isn’t always easy to find a good fit and we all understand this, so please do not feel bad about switching.
Appointments are typically scheduled as a 45–50-minute session weekly or biweekly, at a time agreed upon with your clinician. Appointment frequency is determined collaboratively by you and your clinician; therefore, session frequency may vary depending on your situation and needs. Please note, our clinicians may be unavailable on certain days and/or times that you may request or prefer. Should this significantly interfere with your needs, please discuss this with your clinician and/or contact our administration staff. Treatment duration is highly variable depending on presenting concerns, the treatment plan, and other factors. Your Clinician will review your treatment goals and plan with you intermittently throughout your work together. They may also recommend that you have a medical or psychiatric evaluation to aid in the treatment process. It is important to remember that you retain the right to make changes to your treatment or end treatment at any time. At any point, you or your clinician may determine that it is inadvisable to continue therapy and treatment may be concluded. However, if you notice concerns about your treatment or wish to stop, it is our hope that you can discuss these concerns with your clinician and try to adjust our treatment approach. If concerns cannot be resolved, we will be our UCC team and clinicians are happy to provide referrals to alternative mental health professionals. Your input is always welcomed, and your clinicians understand that other forms of treatment may be helpful.
We accept payment directly from insurance companies. As a courtesy we are happy to bill most insurance companies directly for our services with the understanding that you remain financially responsible for any payment not made by your insurance carrier. Insurance companies often require a formal diagnosis with their claims. Diagnoses are technical terms that describe the nature of your problems and whether they are short-term or long-term problems. Please feel free to discuss your diagnosis with your provider.
Your provider(s) are required to keep appropriate records of the mental health services that they provide. Although mental health treatment often includes discussions of sensitive and private information, normally very brief records are kept noting that you have been here, what was done in session, and a mention of the topics discussed. You have the right to a copy of your file at any time. You have the right to request that a copy of your file be made available to any other health care provider at your written request. Your records are maintained in a secure location in the office. We utilize an electronic medical record system (EMR) that securely houses patient information.
The confidentiality of all communications between a patient and mental health provider is generally protected by law. Urban Counseling Collective and your provider(s) cannot and will not tell anyone else what you have discussed or even that you are in treatment without your written permission. In most situations, Urban Counseling Collective and your provider(s) can only release information about your treatment to others outside of the practice if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. Providers at Urban Counseling Collective may share your clinical information when consulting with one another and/or when coordinating your care when it is deemed in their professional judgment, to be clinically appropriate. All members of the group Urban Counseling Collective are bound by the laws and rules surrounding confidentiality for their given licenses and by the terms of this statement. With the exception of certain specific situations described below, you have the right to confidentiality of your treatment. You, on the other hand, may request that information is shared with whomever you choose, and you may revoke that permission in writing at any time. There are, however, several exceptions in which your provider is legally bound to take action even though that requires revealing some information about a patient's treatment. If at all possible, your provider will make every attempt to inform you when these will have to be put into effect. The legal exceptions to confidentiality include, but are not limited to the following:
1. If there is good reason to believe you are threatening serious bodily harm to yourself or others. If a provider believes a patient is threatening serious bodily harm to another, the provider may be required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a patient threatens harm to him/herself or another, the provider may be required to seek hospitalization for the patient, or to contact family members or others who can provide protection.
2. If there is good reason to suspect, or evidence of, abuse and/or neglect toward children, the elderly or disabled persons. In such a situation, your provider is required by law to file a report with the appropriate state agency.
3. In response to a court order or where otherwise required by law.
4. To the extent necessary, make a claim on a delinquent account via a collection agency.
5. To the extent necessary for emergency medical care to be rendered.
Finally, there are times when your provider may find it beneficial to consult with colleagues as part of a peer-consultation practice for mutual professional consultation. Your name and unique identifying characteristics will not be disclosed. The consultant is also legally bound to keep the information confidential.
POSSIBLE REFERRAL FOR HIGHER LEVEL OF CARE
Please note that your clinician may, at the clinician’s sole discretion, determine at the first or any subsequent session, that you require a higher level of care or treatment beyond what can be provided in our outpatient group private practice. In such a case, your clinician is bound by ethical duty to refer you for treatment that more closely meets your needs.
Services provided by a Psychiatrist or Nurse Practitioner.
If enrolled in Medication Management with UCC, additional information and consents will be provided. Generally, your prescribing clinician may provide psychiatric services that are within their education, training, and experience. These services may include: Ordering and/or performing diagnostic and therapeutic procedures, formulating a working diagnosis, developing, and implementing a treatment plan, monitoring the effectiveness of therapeutic interventions, offering counseling and education, supplying sample medications, and writing prescriptions, and asking appropriate referrals
Please allow up to 72 hours for your request to be processed and sent to your pharmacy. Some refill requests will require a visit with your provider prior to being processed.
TREATMENT OF MINORS
In order to authorize mental health treatment for a child, you must have either sole or joint legal custody of that child. If you are separated or divorced from the other parent of your child, or there are other legal arrangements regarding custody, please notify the administrative staff prior to intake. We will ask you to provide UCC with a copy of the most recent custody agreement that establishes custody rights of you and the other caregiver(s), or otherwise demonstrates that you have the right to make medical decisions and authorize treatment for the minor. Generally, we expect parents/guardians to communicate with each other about services, decide who will schedule appointments, who will bring the child to treatment, etc. The clinician and the child cannot be messengers between parents. If clinically indicated, caregivers will be included in treatment for the benefit of the child. Participation in therapy from both parents is expected, if determined to be clinically appropriate by your clinician. Additionally, you will be asked to sign a separate Child Treatment Policy document.
For Minors: If you are under eighteen years of age, please be aware that the law may provide your parents (custodial and non-custodial guardians) the right to examine your treatment records. If a child is at an age where privacy is clinically appropriate, it is our policy to request an agreement from parents that they agree to give up access to your records. If they agree, your clinician will provide them only with general information about our work together, unless your clinician feels there is a high risk that you will seriously harm yourself or someone else. In this case, your clinician will notify them of the concern. We will also provide them with a summary of your treatment when it is complete, if requested. Before giving them any information, we will discuss the matter with you, if possible, and do our best to handle any objections you may have with what we are prepared to discuss.
Minors 14-years-old or older: In Oregon minors aged 14 years and older can seek mental health treatment without the consent of their parent/guardian. While there are some occasions when it is inadvisable to notify parents/guardians about your involvement in therapy, in Oregon it is expected that a parent/guardian will be involved in treatment before treatment is concluded. Often, this means meeting with a parent/guardian initially to discuss the importance of confidentiality and privacy in your therapy. Most things that you discuss in session will not be shared with others. However, if there is a reason your clinician feels the need to share something with your parent/guardian, they will discuss it with you beforehand. You have the right to ask your clinician about the sharing policy at any time during therapy.
For Parents/Guardians: In any therapy relationship, confidentiality and trust are cornerstones of successful treatment. For this reason, the minor has rights to confidentiality, and their clinician will likely not share the details of what was discussed in therapy if it would be detrimental to the minor in any way. However, if the minor discloses any life-threatening, safety, or risk concerns, you will be notified as soon as possible, unless there are concerns that this communication may cause further harm to the minor. If the minor is participating in any undesirable activities, your clinician will likely keep the minor’s activities and behaviors confidential, unless confidentiality would result in imminent harm.
DRUGS AND ALCOHOL
A patient who attends an appointment under the influence of drugs or alcohol may not be seen. Such an incident will be treated as a “no-show” and a late cancel/no-show fee may be charged (see Financial Policy).
LEGAL PROCEEDINGS AND COURT INVOLVEMENT
If you are involved in or anticipate being involved in any legal or court-related proceedings, we expect you to notify your clinician as soon as possible. It is important for your clinician to understand how, if at all, your involvement in these proceedings might affect your work together. Urban Counseling Collective’s providers, employees, contractors, Residents, and/or interns will not voluntarily participate in any litigation, or custody dispute in which a patient or their representative/guardian and another individual, or entity, are parties. UCC providers will also not make any recommendation as to custody or visitation regarding our patients. Because the patient-mental health provider relationship is built on trust with the foundation of that trust being confidentiality, it is often damaging to the therapeutic relationship for the mental health provider to be asked to present records to the court, testify whether factual or in an expert nature, in court or deposition. Therefore, if your provider has any involvement with legal proceedings it will likely result in the need to terminate mental health treatment and refer you to another mental health provider. In such cases as the mental health provider is ordered to testify by the court about his/her counseling with you, the mental health provider will be monetarily compensated as set forth below:
In the event that it is necessary for the mental health provider to testify before any court, arbitrator, or other hearing officer to testify at a deposition, whether the testimony is factual or expert, or to present any or all records pertaining to the counseling relationship to a court official, the patient agrees to pay the therapist for his or her services, including travel, preparation, and necessary expenditures (copies, parking, meals, and the like) @ the rate of $250.00 per hour, rounded to the nearest half hour. The patient further agrees to pay the $2,000.00 (8 hours x $250.00) two weeks prior to the appearance, presentation of records, or testimony requested. This will be the case even if the therapist is called to testify by another party.
UCC will provide a written summary of your treatment upon your request. With couples, this request needs to be signed by both patients. UCC is not obligated to provide recommendations outside of what is clinically indicated for your mental health treatment. This includes recommendations to courts, doctors regarding surgeries or medical procedures, your employer or insurer for readiness to work, your school for education recommendations or limitations, or your housing administration for companion or emotional support animals. (Emotional Support Animal letters may be written with clinician discretion, but may be declined, due to licensing and ethical limitations).
FAMILY MEDICAL LEAVE ACT (FMLA) PAPERWORK
You are responsible for requesting that your primary care provider (PCP) complete any necessary FMLA paperwork. Our clinic will provide chart notes if necessary to assist with FMLA processing. A release of information is required to be signed by you to release any protected health information. Your clinician may be able to complete FMLA paperwork after the completion of three sessions with you. At that time, your clinician will determine if it is appropriate for the completion of FMLA paperwork and will discuss with you what may be disclosed in such paperwork. The patient understands that based on their professional discretion. Please understand that UCC is not responsible for the outcome of your request for FMLA (I.e., your FMLA request may be approved or denied by their employer. the requesting party).
CONTACTING YOUR CLINICIAN
Your clinician is often not immediately available by telephone, but reception is typically available from 9 AM to 5PM, Monday through Friday, excluding Federal holidays. During times when no one is available to take your call, please leave a message and your call will be returned within the next business day. In an emergency, please call 911 or proceed to the nearest emergency room.
For urgent matters, please call the office phone for further instructions. For any number of unseen reasons, if you do not hear from your clinician or your clinician is unable to reach you, it remains your responsibility to take care of yourself until such time as you and your clinician can talk. If you feel unable to keep yourself safe, go to your nearest emergency room. Your clinician will make every attempt to inform you in advance of any planned absences and provide you with the name and phone number of the clinician covering the practice.
CONSENT TO TEXT MESSAGING, E-MAIL, AND OTHER SECURE ELECTRONIC COMMUNICATION
In order to enhance patient care, our practice may contact you via phone call, voicemail, SMS text message, e-mail, or mobile application, some of which may be via automated means to remind you of an appointment, to obtain feedback on your experience with our mental healthcare team, or to provide other information. You understand and agree to be contacted in this manner with communications related to your initial and any future appointments. In the future, you may opt out of receiving messages by notifying us in writing at firstname.lastname@example.org
Child abuse: If your clinician has reasonable cause to believe that any child with whom they have had direct contact has been abused or that any adult with whom they have had contact has abused a child, your clinician may be required to report the abuse. In any child abuse investigation, the clinician may be required to disclose protected health information (PHI). Regardless of whether or not they are required to disclose PHI, the clinician also has an ethical obligation to prevent harm to their patients and others. Your clinician will use their professional judgment to determine whether they release PHI to prevent serious harm.
Abuse of mentally ill or developmentally disabled adults: If your clinician has reasonable cause to believe that any mentally ill or developmentally disabled individual, who received services from a community program or facility, has been abused, they may be required to report the abuse. Additionally, if your clinician has reasonable cause to believe that any adult with whom they have had direct contact has abused a mentally ill or developmentally disabled individual, they may be required to report the abuse. In any abuse investigation, they may be required to disclose PHI. Regardless of whether or not they are required to disclose PHI, your clinician also has an ethical obligation to prevent harm to their patients and others. Your clinician will use their professional judgment to determine whether they release PHI to prevent serious harm.
Elder abuse: If your clinician has reasonable cause to believe that any elder with whom they have had direct contact has been abused or that any adult with whom they have had contact has abused an elder, they may be required to report the abuse.
Occasionally we may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using identifying information.
SEEING CLINICIAN IN PUBLIC
If you see your clinician accidentally outside of the therapy office, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us and we do not wish to jeopardize your privacy. However, if you acknowledge your clinician first, your clinician will be more than happy to speak briefly with you but feel it not appropriate to engage in any lengthy discussions in public or outside of the therapy office.
If you are feeling unsatisfied with the process of your mental health treatment, please discuss this with your clinician so that both of you can respond accordingly. Such feedback will be taken seriously and with care and respect. Feedback is essential to the therapeutic process. You may also request that you be referred to another clinician and are free to end therapy at any time.
You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment.
You have the right to ask questions about any aspect of your mental health treatment and about your clinician's specific training and experience. You have the right to expect that your clinician will not have personal, social, occupational, or other forms of relationships with patients or with former patients; your relationship with your clinician is based on creating a safe therapeutic alliance, and your clinician has an ethical obligation to avoid multiple relationships.
Patients of Urban Counseling Collective are required to:
• Present an insurance card at the time of service
• Present a picture ID (driver's license preferred) for verification of identity
• Inform us immediately if the patient's insurance carrier changes and provide us with a copy (front and back) of the
• new card.
• Pay the correct co-pay, co-insurance and/or un-met deductibles at the TIME OF SERVICE. We are required by
• our insurance contract to collect patient copays.
• Assume financial responsibility for any and all charges your health insurance company does not pay for. This
• includes patient co-pay, co-insurance, policy deductible, and any and all non-covered services and the outstanding balance after the insurance company has submitted payment to Urban Counseling Collective.
• Keep a valid credit card on file with Urban Counseling Collective to be used for any account balance including co-pays, co-insurance, deductibles, late cancel fees and/or no-show fees.
• Pay the account balance in full immediately upon receiving a statement from Urban Counseling Collective of outstanding charges. An unpaid balance above $200 may result in termination from the practice.
RESPONSIBILITY FOR PAYMENT
Even though a patient may have health insurance, the patient is the guarantor, and the patient is responsible for payment of services provided by Urban Counseling Collective. Urban Counseling Collective will bill the patient's PRIMARY insurance company in most circumstances for all services rendered with the information the patient has provided. The patient is responsible for notifying us immediately if insurance information has changed, so we may bill the correct insurance carrier. Our ability to bill your secondary insurance is dependent on limitations in our EHR program and therefore we may be unable to bill secondary insurance on your behalf. Once the insurance company has processed the patient's claim, Urban Counseling Collective will post any payment it receives to the patient's account. If there is a remaining balance, the balance will become the patient's responsibility and is due immediately upon receipt. This balance may include deductibles, co-insurance and any and all non-covered charges. Payment for this balance is due immediately upon the patient's receiving our statement of outstanding charges. Should a balance accrue, and no payment is received, Urban Counseling Collective reserves the right to terminate services for non-payment and/or seek remuneration by any means legally possible including, but not limited to, the retention of a collection agency.
Counseling sessions with a licensed therapist are billed at $100 to $200; Therapy sessions with a licensed Psychologist or Psychologist Resident are billed at $150 to $300; Psychiatric sessions with a Psychiatric Nurse Practitioner are billed at $150 to $350; pre-licensed therapist fees are $60 to $100 per 45-minute session; and graduate student intern therapist fees are $25 to $60 per 45-minute session. Fees will be re-evaluated periodically
In the case that an insurance company is being billed for services, Urban Counseling Collective will provide a courtesy benefit check in order to provide the patient with benefit information and the estimated patient contribution. This is not a guarantee of benefits or payment owed; and patients are encouraged to contact their insurance companies to confirm benefits and eligibility. Contracted rates with insurance companies are subject to change.
No Shows and Late Cancellations
Mental health services are most effective when session meeting times are regular and consistent. If patients need to cancel or reschedule a session, it is expected that they will provide 24-hour "Business Day" notice. "Business day" notice means, for example, that for a Monday cancellation, you are asked to cancel by the preceding Friday, at or before the time of your scheduled appointment on Monday. For a post-holiday cancellation, please allow for one additional business day for your notice. If you miss an appointment without canceling or notifying the office or your clinician, or if you are cancelling your appointment with less than 24 hours "business day" notice, you will be billed $100 (ONE HUNDRED DOLLARS US). It is important to note that insurance companies do not provide reimbursement for no-show or late canceled sessions. This means that you as the patient are responsible for this fee. In addition, patients are responsible for coming to sessions on time, at the time of the scheduled appointment. If you are late, the appointment will still need to end on time. If you are more than 15 minutes late to a scheduled follow-up psychotherapy appointment or 10 minutes late to an initial mental health intake/assessment or any psychiatric appointment, the clinician may no longer be able to see you, and the no show/late cancellation fee of $100 will apply. Additionally, if you present to an appointment under the influence of a substance or are otherwise unable to participate, the appointment will be considered a late cancellation and the $100 fee may be applied. If the clinician is late, you as the patient will still receive the full session time. If a patient misses two (2) appointments without providing proper notice, that patient may be discharged from the practice and provided with appropriate referrals for care.
PRIMARY INSURANCE CLAIMS
As a courtesy, in most circumstances we will file claims with the patient's primary insurance upon the patient's submission of proof of insurance (insurance card indicating coverage, identification number, group number and subscriber demographics). Exceptions do apply and Urban Counseling Collective is not at any point obligated to bill any insurance company. In the event the patient has insurance coverage but cannot provide documentation, full payment is due at the time of service. If the insurance company does not pay within 30 days following the date of service, the patient is responsible for the remaining balance. Urban Counseling Collective reserves the right to require payment in full for out of network services covered by certain insurance carriers with whom Urban Counseling Collective is NOT a preferred provider organization.
Urban Counseling Collective will need to know which insurance is primary. If you are unsure, please contact your insurance company directly to determine this. We only bill secondary insurance with our in-network carriers. We are happy to provide patients with receipts for service so the patient may self-submit claims to a secondary carrier.
REFERRALS AND AUTHORIZATIONS
If a patient has an insurance plan that requires a referral from a primary care physician prior and/or an authorization by the insurance company to visit a mental health professional, it is the patient's responsibility to obtain the referral. If the patient chooses to seek the services of a mental health professional without the referral, the patient will be responsible for the payment of the charges.
CREDIT CARD ON FILE
Patients are required to keep a valid credit card on file and, per this financial agreement, authorize Urban Counseling Collective to charge the credit card for any unpaid account balances including co-pays, coinsurance, deductibles, late cancel fees and/or no-show fees.
FORMS OF PAYMENT
In order to provide efficient billing services, Urban Counseling Collective accepts credit card payments only.
PARENTS/GUARDIANS ARE RESPONSIBLE FOR PAYMENT
Parents/Guardians are responsible for any co-payments, deductibles, and non-covered services. This office considers the parent/guardian bringing the child in for mental health treatment financially responsible for any charges arising for that date of service, regardless of any custody issues. Any court orders regarding responsibility for such costs are to be enforced by the courts and do not determine who we bill for a child's care.
Patients unable to pay a patient statement balance in full upon receipt of statement or a copay at the time of the visit are strongly encouraged to contact us at 503-610-2044 to discuss payment options. Unless a payment arrangement is made, the card on file will be charged for the outstanding balance within 5 days.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR RESPONSIBILITIES:
We reserve the right to change this Notice of Privacy Practices and to make any new Notice of Privacy Practices effective for all protected health information that we maintain. Any new Notice of Privacy Practices adopted can be made available at your next appointment.
II. WHAT IS PROTECTED HEALTH INFORMATION (PHI)?
Protected health information ("PHI") is demographic and individually identifiable health information that will or may identify the patient and relates to the patient's past, present or future physical or mental health or condition and related health care services.
III. USES AND DISCLOSURES OF INFORMATION
Under federal law, we are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations.
IV. WHAT DOES "HEALTH CARE OPERATIONS" INCLUDE?
Health care operations include activities such as communications among health care providers, conducting quality assessment and improvement activities; evaluating the qualifications, competence, and performance of healthcare professionals; training future healthcare professionals; other related services that may be a benefit to you such as case management and care coordination; contracting with insurance companies: conducting medical review and auditing services; compiling and analyzing information in anticipation of or for use in legal proceedings; and general administrative and business functions.
V. HOW IS MEDICAL INFORMATION USED?
We use medical records as a way of recording health information, planning care and treatment and as a tool for routine healthcare operations. Your insurance company may request information such as procedure and diagnosis information that we are required to submit in order to bill for treatment we provide to the patient. Other health care providers or health plans reviewing your records must follow the same confidentiality laws and rules required of us. Patient records are also a valuable tool used by researchers in finding the best possible treatment for diseases and medical conditions. All researchers must follow the same rules and laws that other health care providers are required to follow to ensure the privacy of patient information. Information that may identify patients will not be released for research purposes to anyone without written authorization from the patient or the patient's parent or legal guardian.
VI. HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT, OR HEALTHCARE OPERATIONS
* Medical information may be used to justify needed patient care services, (i.e., lab tests, prescriptions, treatment protocols, research inclusion criteria).
* We will use medical information to establish a treatment plan.
* We may disclose protected health information to another provider for treatment (i.e., referring physicians, specialists and providers, therapists, etc.)
* We may submit claims to your insurance company containing medical information and we may contact their utilization review department to receive pre-certification (prior approval for treatment).
* We will submit only the minimum amount of information necessary for this purpose.
* We may use the emergency contact information you provided to contact you if the address of record is no longer accurate.
* We may contact you to remind you of your appointment by calling, emailing, or texting you.
* We may contact you to discuss treatment alternatives or other health related benefits that may be of interest.
VII. WHY DO I HAVE TO SIGN A CONSENT FORM?
When you, as the patient or guardian of a patient, sign a consent form, you are giving us permission to use and disclose protected health information for the purposes of treatment, payment, and health care operations. This permission does not include psychotherapy notes, psychosocial information, alcoholism and drug abuse treatment records and other privileged categories of information which require a separate authorization. You will need to sign a separate authorization to have protected health information released for any reason other than treatment, payment, or healthcare operations.
VIII. WHAT ARE PSYCHOTHERAPY NOTES?
Psychotherapy notes are notes recorded (in any medium) by a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session that are separated from the rest of the patient's medical record. Psychotherapy notes exclude medication prescription and monitoring, counseling session start and stop times, modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
IX. WHAT IS PSYCHOSOCIAL INFORMATION?
Psychosocial information is information provided regarding your social history and counseling or psychiatric services you have received before treatment with me.
X. WHY DO I HAVE TO SIGN A SEPARATE AUTHORIZATION FORM?
In order to release patient protected health information for any reason other than treatment, payment, and health care operations, we must have an authorization signed by the patient or the parent or guardian of the patient that clearly explains how they wish the information to be used and disclosed. The following are some examples of releases of information that require a separate authorization:
* Psychosocial information
* Use of information in scientific and educational publications, presentations, and materials.
XI. CAN I CHANGE MY MIND AND REVOKE AN AUTHORIZATION?
You may change your mind and revoke an authorization, except (1) to the extent that we have relied on the authorization up to that point, (2) the information is needed to maintain the integrity of the research study, or (3) if the authorization was obtained as a condition of obtaining insurance coverage. All requests to revoke an authorization should be in writing.
XII. SHARING INFORMATION WITH BUSINESS ASSOCIATES
There are some services provided through contracts with business associates. Examples include billing services and transcription services. When these services are contracted, we may disclose your health information to the business associate so that they can perform the job we have contracted them to do.
XIII. WHEN IS MY AUTHORIZATION / CONSENT NOT REQUIRED?
The law requires that some information may be disclosed without your authorization in the following circumstances:
● In case of an emergency
● When there are communication or language barriers
● When required by law
● When there are risks to public health
● To conduct health oversight activities
● To report suspected child abuse or neglect or abuse/neglect to other disabled persons
● To specified government regulatory agencies
● In connection with judicial or administrative proceedings
● For law enforcement purposes
● To coroners, funeral directors, and for organ donation
● In the event of a serious threat to health or safety
XIV. YOUR PRIVACY RIGHTS
The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
1. You have the right to inspect and copy your health information. This means you may inspect and obtain a copy of your PHI that is contained in a "designated record set" for so long as we maintain the PHI. A designated record set contains medical and billing records and any other records that we use in making decisions about your healthcare. You may not however, inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and certain PHI that is subject to laws that prohibit access to that PHI. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have the right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
2. You have the right to request a restriction of your health information. This means you may ask us to restrict or limit the medical information we use or disclose for the purposes of treatment, payment, or healthcare operations. We are not required to agree to a restriction that you may request. We will notify you if we deny your request. If we do agree to the requested restriction, we may not use or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. You may request a restriction by contacting our Privacy Officer.
3. You have the right to request to receive confidential communications by alternative means or at alternative locations.
4. We will accommodate reasonable requests. We may also condition this accommodation by asking you for an alternative address or other method of contact. We will not request an explanation from you as the basis for the request. Requests must be made in writing to our Privacy Officer.
5. You have the right to request amendments to your health information. This means you may request an amendment of PHI about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request, you have the right to file a statement of disagreement with our Privacy Office and we may prepare a rebuttal to your statement and will provide you with a copy of this rebuttal. If you wish to amend your PHI, please contact our Privacy Officer. Requests for amendment must be in writing.
6. You have the right to receive an accounting of disclosures of your health information.
7. You have the right to request an accounting of certain disclosures of your PHI. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Privacy Notice. We are also not required to account for disclosures that you requested, disclosures that you agreed to by signing an authorization form, to family or friends involved in your care, or certain other disclosures we are permitted to make without your authorization. The request for an accounting must be made in writing to our Privacy Officer. The request should specify the time period sought for the accounting. Accounting requests may not be made for periods of time in excess of six years.
8. You have the right to receive a paper copy of this Notice of Privacy Practices upon request.
XV. WHAT IF I HAVE A QUESTION / COMPLAINT?
If you have questions regarding your privacy rights, please contact the practice's Privacy Officer at 541-868-2004. If you believe your privacy rights have been violated, you may file a complaint by contacting UCC’s Privacy Officer at 541-868-2004 or the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. The address for the Secretary of the Department of Health and Human Services is:
Office of Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth St., S.W.
Atlanta, GA 30303-8909
(404) 562-7886 (phone) | (404) 562-7881 (fax) | (404) 331-2867 (TDD) | www.hhs.gov/ocr/hipaa
SOCIAL MEDIA POLICY
This section outlines UCC’s policies related to the use of social media. Please read it to understand how your clinician will conduct themself on the Internet as a mental health professional and how you can expect them to respond to various interactions that may occur on the Internet.
If you have any questions about anything within this document, we encourage you to bring them up when you meet your clinician. As new technology develops and the Internet changes, there may be times when this policy needs to be updated. If we do so, we will post an updated copy of the policy on our website.
Friending - Your clinician will not accept friend or contact requests from current or former patients on any social networking site (Facebook, LinkedIn, etc.). UCC believes that adding patients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Following - UCC may publish a blog on the website, or post other forms of social media. We have no expectation that you as a patient will want to follow our blog. UCC’s primary concern is your privacy. Your clinician and UCC will not follow you back. Our reasoning is that casual viewing of patients’ online content outside of the therapy hour can create confusion in regard to whether it’s being done as a part of your treatment or to satisfy personal curiosity. In addition, viewing your online activities without your consent and without our explicit arrangement towards a specific purpose could potentially have a negative influence on our working relationship. If there are things from your online life that you wish to share with me, please bring them into our sessions where we can view and explore them together, during the therapy hour.
Interacting - Please do not use SMS (mobile phone text messaging) or messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact your clinicians or UCC. These sites are not secure, and we do not check or respond to these messages. Do not use Wall postings, @replies, or other means of engaging with your clinician in public online if there is an already established patient/therapist relationship. Engaging with your clinician in this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart.
Use of Search Engines - It is NOT a regular part of UCC and your clinicians practice to search for patients on Google or Facebook or other search engines. Extremely rare exceptions may be made during times of crisis. If your clinician has a reason to suspect that you are in danger and you have not been in touch with me via the usual means of coming to appointments, phone, or portal messaging there might be an instance in which using a search engine (to find you, find someone close to you, or to check on your recent status updates) becomes necessary as part of ensuring your welfare. These are unusual situations and if your clinician ever resorts to such means, they will fully document it and discuss it with you at your next appointment.
Business Review Sites - You may find UCC or individual clinicians' professional practice on sites such as Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find UCC or your clinician’s listing on any of these sites, please know that our listing is NOT a request for a testimonial, rating, or endorsement from you as patient of UCC
Of course, you have a right to express yourself on any site you wish. But due to confidentiality, UCC cannot directly respond to any review on any of these sites whether it is positive or negative. We urge you to take your own privacy as seriously as we take our commitment of confidentiality to you. You should also be aware that if you are using these sites to communicate indirectly with us about your feelings about our work, there is a good possibility that we may never see it.
If you are working with a clinician, we hope that you will bring your feelings and reactions to that work directly into the therapy process. This can be an important part of therapy, even if you decide we are not a good fit.
If you feel your clinician has done something harmful or unethical and you do not feel comfortable discussing it with them, you can call and speak with a supervisor. You can always contact the Board of licensing of your therapist, and they will review the services your therapist has provided.
Location-Based Services - If you used location-based services on your mobile phone, you may wish to be aware of the privacy issues related to using these services. We do not place our practice as a check-in location on various sites such as Foursquare, Gowalla, Loopt, etc. However, if you have GPS tracking enabled on your device, it is possible that others may surmise that you are a therapy patient due to regular check-ins at our office on a weekly basis. Please be aware of this risk if you are intentionally “checking in,” from the UCC office or if you have a passive LBS app enabled on your phone.
VIDEO TELEHEALTH PATIENT INFORMED CONSENT AGREEMENT
Telehealth is the delivery of mental health services using interactive audio and visual electronic systems where the mental health clinician and the patient are not in the same physical location. The interactive electronic systems used in telehealth incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.
If you are not located in Oregon at the time of your telehealth appointment, your clinician will be unable to see you due to professional ethics and licensure laws. This may result in a no-show/late cancellation fee.
Potential benefits include increased accessibility to mental healthcare and patient convenience.
Potential Risks. As with any behavioral health procedure, there may be potential risks associated with the use of telehealth. These risks include, but may not be limited to:
• Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate mental health decision making by your telehealth clinician.
• Your telehealth clinician may not be able to provide mental health treatment using interactive electronic equipment nor provide for or arrange for emergency care that you may require.
• Delays in mental health evaluation and treatment may occur due to deficiencies or failures of the equipment.
• Security protocols can fail, causing a breach of privacy of my confidential mental health information.
• A lack of access to all the information that might be available in a face-to-face visit but not in a telehealth session may result in errors in mental health judgment.
Alternatives to the use of telehealth: Traditional face-to-face sessions in our Oregon offices.
• You understand that the laws that protect the privacy and confidentiality of mental health information also apply to telehealth.
• You understand that the technology used by Urban Counseling Collective is encrypted to prevent unauthorized access to your private mental health information.
• You have the right to withhold or withdraw your consent to the use of telehealth during the course of your care at any time. You understand that your withdrawal of consent will not affect any future care or treatment.
• You understand that your clinician has the right to withhold or withdraw his consent for the use of telehealth during the course of your care at any time.
• You understand that the rules and regulations which apply to the practice of psychotherapy and psychiatry in the state of Oregon also apply to telehealth.
• You will not record any telehealth sessions without written consent from your clinician. You understand that your clinician will not record any of our telehealth sessions without your written consent.
• You will inform your clinician if any other person can hear or see any part of our session before the session begins.
• Your clinician will inform you if any other person can hear or see any part of our session before the session begins.
• You understand that you, not your clinician, are responsible for the configuration of any electronic equipment used on your computer which is used for telehealth. You understand that it is your responsibility to ensure the proper functioning of all electronic equipment before your session begins.
• You understand that you must be a resident of the state of Oregon to be eligible for telehealth services from your clinician.
• You will be required to verify your identity to your clinician’s satisfaction.
• You authorize your insurance to be billed for your telehealth sessions.
• You agree to assume financial responsibility for any and all charges your health insurance company does not pay for telehealth services. This includes patient co-pay, co-insurance, policy deductible, and any and all non-covered services and the outstanding balance after the insurance company has submitted payment to Urban Counseling Collective.
YOU CONSENT TO MENTAL HEALTH TREATMENT AND CONSENT TO ALL TERMS AND CONDITIONS OF THE ABOVE DOCUMENTATION. YOU UNDERSTAND THAT URBAN COUNSELING COLLECTIVE RESERVES THE EXCLUSIVE RIGHT TO ACCEPT OR DENY YOU AS A NEW PATIENT AND THAT ACCEPTANCE OR DENIAL OF NEW PATIENT STATUS WILL ONLY BE COMMUNICATED ONCE WE REVIEW THE INFORMATION YOU PROVIDED IN THIS ELECTRONIC DOCUMENT.
Your electronic signature below indicates that:
• You have read the PATIENT AGREEMENT AND INFORMED CONSENT portion of this document and agree to all terms listed within. It also serves as an acknowledgment that you have received the HIPAA Notice Form described above.
• You have read the above FINANCIAL POLICY portion of this document and agree to all terms listed within.
• You have read the PRIVACY PRACTICES portion of this document and agree to all terms listed within. You are aware of the $100 no show/late cancellation fee.
• You have read the above SOCIAL MEDIA POLICY portion and agree to all terms listed within.
• You have read the VIDEO TELEHEALTH PATIENT INFORMED CONSENT AGREEMENT and agree to all terms listed within. Please note, if you are not located in the State of Oregon at the time of your appointment, your clinician will be unable to keep your appointment and may charge a late cancellation fee.