Welcome to our practice. 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. The law requires that we obtain your signature acknowledging we provided you with this information at the end of the initial session. Although these documents are long and sometimes complex, it is very important that you read them carefully before your session. You and your professional can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between you, ATAGF, and your professional.
YOUR PROFESSIONAL
Your professional is a Licensed Psychologist (LP), Psychology Resident, a Licensed Professional Clinical Counselor (LPCC), or a Licensed Clinical Social Worker (LCSW). Individuals who are Licensed Psychologists have a PhD in Clinical or Counseling Psychology and have completed the requirements for licensure as a psychologist in the state of North Dakota. Individuals who are Psychology Residents have a PhD in Clinical or Counseling Psychology, are supervised by a Licensed Psychologist in our practice, and are working toward completing the requirements for licensure as a psychologist in the State of North Dakota. Psychology Residents will provide you with the name of his or her supervisor during the initial session. Individuals who are LPCCs have a master’s degree in Counseling and have completed the requirements for licensure as a counselor in the state of North Dakota. Individuals who are LCSWs have a master’s degree in Social Work and have completed the requirements for licensure as social workers in the state of North Dakota. Some of our professionals are licensed in states in addition to North Dakota and will share this information with you if it is relevant to your work with them.
PSYCHOLOGICAL SERVICES
You are likely coming to ATAGF for psychotherapy (or therapy), psychological testing, or both. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the professional and patient and the problems you are experiencing. There are many different methods we may use to deal with the problems you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. For therapy to be most successful, you will have to work on things you and your professional talk about both during your sessions and at home.
The length of therapy varies based upon goals you establish with your professional, your symptoms, their severity, frequency of sessions, your motivation to participate in therapy, and your ability to implement learned skills outside of session. The length of a psychological evaluation will depend upon the referral question being answered, your symptoms, and your attendance at scheduled sessions.
Therapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Yet, there are no guarantees of what you will experience. Alternatives to individual therapy include group therapy and psychotropic medication, and your professional can provide referrals for these alternatives, if desired.
The first few sessions with your professional will involve an evaluation of your needs. Part of this evaluation may involve completing psychological testing with your psychologist/psychology resident or with a psychology technician (who is supervised by a licensed psychologist). By the end of the evaluation, your professional will be able to offer you some first impressions of what your work together will include. There may also be a treatment plan to follow which may include referrals to other professionals for services (such as group therapy and/or other treatment recommendations). You should evaluate this information along with your own opinions of whether you feel comfortable working with these professionals. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the professional you select. If you have questions about our procedures at ATAGF, you should discuss them with your professional whenever they arise. If your doubts persist, your professional will be happy to help you set up a meeting with another mental health professional for a second opinion.
SOCIAL MEDIA
ATAGF has several social media profiles to share information about relevant topics (psychology, mental health, events, etc.). Because we are active on social media, we have a Social Media Policy that outlines office policies related to use of social media. This policy is available on our website at www.grandforkstherapy.com/social-media-policy or by request. You are encouraged to view this policy and discuss any questions you have with your professional or staff member.
MEETINGS
Our professionals normally conduct an evaluation during the first session that typically consists of answering questions. During this time, you and the professional can both decide if he/she is the best person to provide the services you need to meet your treatment goals. If psychotherapy is begun, your professional will usually schedule one 45-minute session (one appointment hour of 45 minutes duration) per week at a time you agree on, although some sessions may be shorter / longer or more / less frequent. If you are coming for psychological testing, this testing is likely to be conducted in several different sessions. Your professional will be able to discuss his/her plan for testing with you after the initial session.
Once an appointment hour is scheduled, you are asked to provide 24 hours [1 day] advance notice of cancellation if you are unable to make it to your appointment. Although ATAGF provides reminder calls or SMS (text) messages for appointment times as a courtesy, it is your responsibility to know when you are scheduled to meet with your professional. Given reminder calls or SMS (text) messages can be made less than 24 hours in advance, if you cancel when you get your reminder, it is likely that your cancellation will be considered a late cancellation/no-show. After two late cancellations and/or no-shows, ATAGF professionals reserve the right to remove you from a regular spot in their schedules and speak with you prior to scheduling additional appointments to determine your commitment to therapy and/or the psychological evaluation.
PROFESSIONAL FEES
The fees involved for services at ATAGF depend upon the service and type of professional involved. Please contact ATAGF administrative staff or speak with your professional for more information about fees for the services provided to you. In addition to regularly scheduled appointments, ATAGF professional may charge for other professional services you may need, although the professional will break down the hourly cost if he/she works for periods of less than one hour. Other services may include but are not limited to telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of your professional. If you become involved in legal proceedings that require your professional’s participation, you will be expected to pay for all of your professional’s professional time, including preparation and transportation costs, even if your professional is called to testify by another party. Because of the difficulty of legal involvement, ATAGF professionals charge more than the hourly rate for preparation and attendance at any legal proceeding. You are encouraged to discuss this fee with your professionals prior to any legal involvement.
CONTACTING YOUR PROFESSIONAL
Due to the work schedules of our professionals, they are often not immediately available by telephone. Although ATAGF professionals are usually in the office between 8 AM and 5 PM these hours vary based upon the individual professional with whom you are working. Please discuss your professional’s office hours with him/her. Your professional probably will not be available when he/she is with a patient. The telephone is answered by an administrative assistant 8am to 8pm Monday through Thursday and from 8am to 5pm on Friday. These administrative assistants know where to reach your professional and may inform you when he or she is available to speak with you.
Your professional will make every effort to return your call on the same day you make it, except for evenings, weekends, and holidays. If you are difficult to reach, please inform ATAGF administrative assistants of times when you will be available. If you are unable to reach your professional and feel that you cannot wait for him/her to return your call, it is advised you call 911, go to your local Emergency Room, call the 24-hour crisis line at Northeast Human Service Center at (701) 775-0525, or call the University of North Dakota (UND) Crisis Line at 701-777-2127 (press “1” after 4:30pm CT for FIRSTLINK) if you are a UND student. If your professional will be unavailable for an extended time, he/she will provide you with the name of a colleague to contact, if necessary. PLEASE NOTE: ATAGF professionals do not carry a pager and are not available 24 hours a day. If you believe you may need such crisis services, ATAGF may not be the best practice for you.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a professional. In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require you to provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
- Your professional may occasionally find it helpful to consult other medical and mental health professionals about a case. During a consultation, he/she makes every effort to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you do not object, your professional will not tell you about these consultations unless he/she feels it is important to your work together. Your professional will note consultations in your Clinical Record (which is called “PHI” in our Notice of Privacy Practices attached to this Agreement).
- You should be aware ATAGF professionals practice with other mental health professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of your professional staff member.
- We also have contracts with various entities that enable us to perform treatment, billing, and practice management operations. As required by HIPAA, we have formal business associate contracts with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of these organizations and/or a blank copy of this contract.
- Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
- If a patient threatens to seriously harm himself/herself or someone else, your professional or ATAGF staff may take actions to prevent this, including seeking hospitalization for him/her, notifying law enforcement, or contacting family members or others who can help provide protection.
There are some situations where ATAGF is permitted or required to disclose information without either your consent or authorization:
- If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis and treatment, such information is protected by the professional-patient privilege law. ATAGF professionals cannot provide any information without your written authorization or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your professional to disclose information.
- If a government agency is requesting the information for health oversight activities, your professional may be required to provide it for them.
- If a patient files a complaint or lawsuit against an employee of ATAGF, the ATAGF employee may disclose relevant information regarding that patient to defend him or herself.
- If a patient files a worker’s compensation claim, ATAGF must, upon appropriate request, provide appropriate information including a copy of the patient’s record or other information concerning mental health care services, to the North Dakota Worker's Compensation Bureau.
There are some situations in which an ATAGF professional is legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment.
- If we have reason to suspect that a child is abused or neglected, the law requires that we file a report with the Department of Human Services. Once such a report is filed, we may be required to provide additional information.
- If we have knowledge of or reasonable cause to suspect that an adult with developmental disabilities or mental illness is abused, neglected, or exploited, the law requires that we report such information to the Protection and Advocacy Project. Once such a report is filed, we may be required to provide additional information.
- If a patient threatens serious physical harm to an identifiable victim, we may take actions to protect the victim. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
If such a situation arises, your professional will make every effort to fully discuss it with you before taking any action and will limit disclosure to what is necessary. Although this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important you and your professional discuss any questions or concerns you may have now or in the future. The laws governing confidentiality can be complex, and your professional is not an attorney. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS
The laws and standards of your professional’s profession require that he/she keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your Clinical Record (or a summary or explanation of the information contained in your Clinical Record if agreed by you in advance), if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, ATAGF recommends that you initially review them in your professional’s presence or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, ATAGF can charge a copying fee of $20 per page for the first 25 pages, 75 cents per page for any pages beyond twenty-five and includes administrative, document retrieval, and postage charges. There may be instances in which your professional does not believe reviewing your record is in your best interest, and this will be discussed with you should this occur.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights regarding your Clinical Record and disclosures of protected health information. These rights include requesting that ATAGF amends your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about ATAGF policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and ATAGF privacy policies and procedures. Your professional or an ATAGF administrative assistant is happy to discuss any rights with you.
MINORS & PARENTS
Patients under 18 years of age who are not emancipated and their guardians should be aware the law may allow guardians to examine their child’s treatment records unless your professional decides that such access is likely to injure the child or the legal guardian and the child’s professional agree otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes ATAGF’s policy to request an agreement from guardians that they consent to give up their access to the child’s records. If they agree, during treatment, the professional will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. The professional may also provide guardians with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless the professional feels the child is in danger or is a danger to someone else, in which case, the professional will notify the guardians of his/her concern. Before giving guardians any information, the professional will discuss the matter with the child, if possible, and do his/her best to handle any objections the child may have.
RECORDING
Your sessions with any ATAGF professional may not be recorded in any way by any party unless agreed to in writing by mutual consent (between you/your guardian and your ATAGF professional). The end date of this mutual consent will be included in the written agreement. A copy of this written agreement will be maintained in your medical record.
APPOINTMENT REMINDERS
ATAGF utilizes electronic SMS messaging (texting) for appointment reminders which may include phone calls with voicemail. It is your responsibility to ensure that contact information is updated with ATAGF staff and that failure to do so may result in someone other than yourself receiving the appointment reminder. You may also choose to opt out of text messaging reminders. To do so, please submit the request to ATAGF staff in writing and appointment reminders will be handled accordingly.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless you have insurance coverage that requires another arrangement, or you and your professional agree otherwise. Credit card payments and similar arrangements are more confidential than checks (with names on them), as we deposit these checks into our banking account. Paym0ent schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, your professional may be willing to negotiate a fee adjustment (if allowed by managed care contracts) or payment plan.
Any outstanding balance (bill) will be sent to the address on file. If you would like someone other than yourself to pay your bill at ATAGF (such as parent of someone over the age of 18), we need additional information from you. We ask you to provide contact information for the individual responsible for the account and provide your written authorization for us to speak with this individual about matters pertaining to your bill. It is your responsibility to update this information if it changes, and you are welcome to change this information at any time.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, ATAGF has the option of using legal means to secure the payment. This may involve hiring a collection agency (i.e., United Accounts) or going through small claims court which will require your professional to disclose otherwise confidential information. In most collection situations, the only information ATAGF releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon or if the arrangements have not been followed, your individual professional may speak with you about a referral to another agency or professional who is able to provide more cost-effective services to you.
INSURANCE REIMBURSEMENT
For you and your professional to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. ATAGF administrative assistants and your professional will fill out forms and provide you with whatever assistance he/she can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of your professional’s fees. It is very important that you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, ATAGF administrative staff will provide you with whatever information they can based on their experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, ATAGF administrative staff will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. Although much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed care plans will not allow professionals to provide services to you once your benefits end. If this is the case, your professional will do his/her best to find another professional who will help you continue your psychotherapy.
You should also be aware that your contract with your health insurance company requires that ATAGF provides it with information relevant to the services that your professional offers to you. Your professional is required to provide a clinical diagnosis. Sometimes your professional is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, your professional will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Although all insurance companies claim to keep such information confidential, ATAGF has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. Your professional will provide you with a copy of any report he/she submits, if you request it in writing. By signing this Agreement, you agree that ATAGF can provide requested information to your carrier.
Once we have all the information about your insurance coverage, you and your professional will discuss what you can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by contract.
CONSENT FOR RELEASE OF PROTECTED HEALTH INFORMATION TO INSURANCE COMPANY
You authorize Assessment and Therapy Associates of Grand Forks, PLLC to disclose to your current insurance carrier past and present information that is necessary to prepare an insurance claim. The insurance company will use this information to process claims for benefits. You authorize all insurance payable on claims originating from Assessment and Therapy Associates of Grand Forks, PLLC to be paid directly to Assessment and Therapy Associates of Grand Forks, PLLC. You understand that no other use will be made of this information except for that otherwise authorized by law.
EMAIL INFORMED CONSENT
Email can be a useful method of correspondence for clients. Transmitting confidential information by email can create several risks, both general and specific that clients need to be aware of if they choose this method of correspondence.
General email risks include but are not limited to the following:
- Email can be immediately broadcasted worldwide and received by many intended and unintended recipients;
- Recipients can forward email messages to other recipients without the original sender’s permission or knowledge;
- Users can easily send an email to the incorrect address;
- Email is easier to falsify than handwritten or signed documents;
- Backup copies of email may exist even after the sender or recipient has deleted his or her copy; and
- Without the benefit of face-to-face interaction, emails can be misinterpreted in tone and meaning.
Specific email risks include but are not limited to the following:
- Email containing information pertaining to a client’s diagnosis and/or treatment must be included in the client’s medical record. Thus, all individuals who have access to the medical record will have access to the email messages;
- If you are sending your emails from your employer’s and/or educational institution’s computer and/or email account, they do have access to your emails;
- While it is against the law to discriminate, an employer who has access to your email could use the information to discriminate against the employee. Additionally, the employee could suffer social stigma from a workplace disclosure;
- Insurance companies who learn of your PHI information could deny you coverage; and
- Although therapists and ATAGF staff will endeavor to read and respond to email correspondence promptly, they cannot guarantee that any email message will be read and responded to within any particular time frame.
Conditions for use of email:
All email messages sent or received that concern your diagnosis or treatment or that are a part of your medical record will be treated as part of your PHI. Reasonable means will be used to protect the security and confidentiality of the email. Because of the risk outlined above, the security and confidentiality of email cannot be guaranteed.
Your consent to email correspondence includes your understanding of the following conditions:
- All emails to and from you concerning your protected health information (PHI) will be a part of your file and can be viewed by health care, insurance professionals, and ATAGF office support staff.
- Your email messages may be forwarded within ATAGF as necessary for diagnosis, treatment, and reimbursement. However, they will not be forwarded outside the office without your consent or as required by law.
- Though all efforts will be made to respond promptly, this may not be the case. Because the response cannot be guaranteed do not use email in a medical or mental health emergency.
- You are responsible for following up with the therapist or support staff if you have not received a response.
- Medical information is sensitive and unauthorized disclosure can be damaging. You should not use email for communications concerning diagnosis or treatment of AIDS/HIV infection, other sexually transmittable diseases, mental health, developmental disability, or substance abuse issues. It is your right, however, to choose to communicate about this information if you desire.
- Since employers and educational institutions do not observe an employee’s or student’s right to privacy in their email system, you should not use their employer’s or educational institution’s email system to transmit or receive confidential emails.
- ATAGF will take reasonable steps to ensure that all information shared through emails is kept private and confidential. However, ATAGF is not liable for improper disclosure of confidential information that is not a result of our negligence or misconduct.
- If you consent to the use of email, you are responsible for informing your professional and ATAGF staff of any type of information that you do not want sent to you by email.
- It is your responsibility to update your email address with ATAGF staff members and professional if it changes.
- You are responsible for protecting your password and access to your email account and any email you send or receive from ATAGF to ensure your confidentiality. ATAGF and its staff members cannot be held liable if there is a breach of confidentiality caused by a breach in your account security.
- Any email that you send that discusses your diagnosis or treatment constitutes informed consent to the information being transmitted. If you wish to discontinue emailing information, you must submit a written notification that you wish to discontinue or an email informing your therapist that you are withdrawing consent to email information.
Please note that not all ATAGF professionals communicate with patients and/or collaterals by email. Please speak with your professional about whether they communicate in this manner.