Practice Policies.
APPOINTMENTS AND CANCELLATIONS
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. The standard meeting time for a medication eval is 20 minutes. Intakes last 60 minutes. A $10.00 service charge will be charged for any checks returned for any reason for special handling. Cancellations and re-scheduled session will be subject to a full charge if NOT RECEIVED AT LEAST 24 HOURS IN ADVANCE. Appointments scheduled for Monday must be cancelled by the same hour as your scheduled appointment the previous Friday. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.
FEES/INSURANCE: We are in network. We work with Cigna, Aetna, and Blue Cross (Oregon only) at this time. If your insurance is not listed above, you can still pay out of pocket. If you are paying out of pocket, you will be charged the day of your session before your session time. Intake appointments cost $250 out of pocket and follow ups cost $150. COPIES OF MEDICAL RECORDS: Should you request a copy of your medical records; the cost is $25.00 per requested record. Payment for your medical records will be due prior to receipt. Please allow at least 2 weeks to prepare medical records.
TELEPHONE ACCESSIBILITY If you need to contact me between sessions, please leave a message on my voice mail or send me an email. I am often not immediately available; however, I will attempt to return your call or email within 48 hours. Please note that Face- to-face sessions are highly preferable to phone sessions. However, in the event that you are sick or need additional support, phone sessions may be available. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients 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.
ELECTRONIC COMMUNICATION I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to upto-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective medication management is often facilitated when the provider gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Providers may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the provider’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally to the therapist.
MINORS If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TELEHEALTH CONSENT, POLICY, and AGREEMENT
This form is in addition to the regular Mental Health and Wellness, Policies, Agreement, and Consent Form and Notice of Privacy Practices for Protected Health Information commonly known as HIPAA. You must sign both in order to participate in Telehealth sessions.
Required Information at Every Visit
• Name, location, and telephone number of the patient at the time of session. This is to ensure that your practitioner is aware of alternative means of treatment should an emergency occur.
• Name, location, and telephone number of the provider at the time of session. Telehealth incorporates email, phone, and video technology. This is to inform you about what you can expect regarding your participation in Telehealth.
Benefits: The benefits of Telehealth are:
1. The ability to expand your choice of service provider.
2. More convenient counseling options including location, time, no driving, etc.
3. Reduces the overall cost and time of therapy due to not having to drive to and from an office.
4. Ability to have real-time monitoring and reduces the wait time for scheduling office appointments.
5. Increased availability of services to homebound clients. clients with limited mobility, and clients without convenient transportation options.
Limitations: It is important to note that there are limitations to Telehealth that can affect the quality of the session(s). These limitations include but are not limited to the following:
1. Due to technology limitations we may not hear all of what you are saying and may need to ask you to repeat things.
2. Technology might fail before or during the telehealth session. Our second line of communication will be via telephone.
3. Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.
4. To reduce the effect of these limitations, we may ask you to describe how you are feeling, thinking, and/or acting in more detail than we would during a face-to-face session. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.
Logistics: When we provide phone/video counseling sessions, we will call you at our scheduled time or send you a link for our secure and HIPAA-compliant platform such as Doxy.me, Spruce, or ZOOM. We expect that you are available at our scheduled time and are prepared, focused, and engaged in the session. We are calling you from a private location where we are the only person in the room (unless otherwise discussed), you also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where there are people or others who can hear you, we cannot be responsible for protecting your confidentiality. Every effort MUST be made on your part to protect your own confidentiality. We suggest you wear a headset to increase confidentiality and also increase the sound quality of our sessions. Please know that we cannot guarantee the privacy or confidentiality of conversations held via phone, as phone conversations can be intercepted either accidentally or intentionally. Please assure you reduce all possibilities of interruptions for the duration of our scheduled appointment.
Please know that per best practices and ethical guidelines, we can only practice in the state(s) we are licensed. That means wherever you permanently reside we must be licensed. You agree to inform us if your therapy location has changed or if you have relocated your domicile to a different jurisdiction.
Connection Loss During Video Sessions: If we lose our connection during a video session, we will call you to troubleshoot the reason we lost connection. If we cannot reach you, we will remain available to you during the entire course of our scheduled session. Should you contact us back and there is time left in your session we will continue. If the reason for a connection loss i.e. technology, battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss of connection is a result of something on our end, we can either complete our session via. phone or plan an alternate time to complete the remaining minutes of our session.
Connection Loss During Phone Sessions: If we lose our phone connection during our session, we will call you back immediately. If we are unable to reach each other due to technological issues, we will attempt to call you twice. If we cannot reach you, we will remain available to you during the entire course of our scheduled session. Should you contact us back and there is time left in your session we will continue. If the reason for a connection loss i.e. technology, your phone battery dying, bad reception, etc. occurs on your part, you will still be charged for the entire session. If the loss of connection is a result of something on our end, we will call you from an alternate number. The number may show up as restricted or blocked please be sure to pick it up.
Safety: If we have concerns about your safety at any time during a phone session, we will need to break confidentiality and call 911 (if located in the same county or emergency services in the area you are located at the time of the call) and/or your emergency contact immediately. Please note that everything in our informed consent that you signed, including all the confidentiality exceptions, still applies during phone/video sessions.
Consent to Participate in Telehealth Sessions: By signing below, you agree that you have read and understand all of the above sections of Telehealth Consent, Policy, and Agreement. You agree that you also understand the limitations associated with participating in Telehealth sessions and consent to attend sessions under the terms described in this document.
Recording of Sessions: In some instances, recording of the session may be utilized. Some providers use dictation software that records the session and then documents the session notes into the electronic medical record. This software is HIPAA compliant, and your information is private and confidential. At other times, recording of sessions may be done for educational purposes. Please let your provider know if you do NOT consent to recording of sessions.
DISCHARGE / TERMINATION FROM PRACTICE POLICY
The following situations are grounds for termination or discharge from Freedom Mental Health.
Should the following occur, your provider will no longer be able to continue providing your mental health care; accordingly, it will be necessary for you to transfer your care to another mental health provider.
-Ongoing pattern for missed or canceled appointments
-Negative findings on the Prescription Drug Monitoring Program website
-Inappropriate use of prescribed controlled substances
-Failure to follow the recommended treatment plan or medical instructions
-The provider cannot provide the level of care necessary to meet the client’s needs
-The provider is relocating outside the service area
-The Client and/or Client’s family is abusive to the provider and/or practice staff, or poses a serious threat of harm to the provider, staff, and/or other patients.
In the event of discharge or termination from Freedom Mental Health the following will occur:
The client will be notified in writing of the discharge/termination from via the patient portal and/or USPS mail. The client will be provided with an adequate supply of medication. The client will be instructed to find a new provider. A brief list of resources will be provided.
CONTROLLED SUBSTANCE POLICY (PLEASE READ CAREFULLY)
The safety and care of our clients is our number one priority! Controlled substances are not prescribed in this practice, as in-person monitoring is not possible. These medications are highly regulated by the Drug Enforcement Agency (DEA). State laws require that additional measures be taken when prescribing controlled substances. We want our clients to know how seriously we take the prescribing of these types of medications.
A controlled substance is generally a drug or chemical whose manufacture, possession, or use is regulated by a government, such as illicitly used drugs or prescription medications that are designated by law. Many of the medications prescribed for ADHD, anxiety, and insomnia are drugs that are considered controlled substances. Some examples in each category include:
ADHD Medications:
Focalin (Dexmethylphenidate)
Ritalin (Methylphenidate)
Adderall (Dextroamphetamine / Amphetamine) or (Amphetamine Salt Combo)
Vyvanse
Anxiety Medications:
Xanax (Alprazolam)
Ativan (Lorazepam)
Valium Diazepam)
Klonopin (Clonazepam)
Tranxene (Clonazepate)
Insomnia Medications:
Ambien (Zolpidem)
Restoril (Temazepam)
Lunesta (Eszopiclone)
Belsomra (Suvorexant)
Sonata (Zaleplon)
Rozerem (Ramelteon)
Monitoring of controlled substances is maintained through the Prescription Drug Monitoring Program. As is required from providers, we obtain, review, and monitor Prescription Drug Monitoring Programs in various states. This includes monitoring for multiple controlled substances prescriptions, multiple providers, usage of multiple pharmacies, and any activity that could be suspicious for misuse. We work closely with pharmacies, as they will often call us if they suspect misuse.
We expect full disclosure from you on any controlled substances you obtain from other sources (even the Emergency Department) while under our care. If it is identified that this information has been hidden or omitted by you, it is grounds for possible immediate dismissal from Freedom Mental Health. If you come to our practice already on controlled substances from another provider, we will not be able to assume these same medications.
Our providers reserve the right to complete their own assessment and make treatment recommendations based on their professional judgment. We appreciate your assistance in this matter, as we take this policy very seriously. These types of drugs are addictive and have a high rate of misuse/abuse. In addition, many of these medications are intended for short-term use only. It is our goal to keep you, our client, as safe as possible.
Health Information Portability and Accountability Act (HIPAA) Notice of Privacy Policy
This document contains important information about federal law, the Health Information Portability and Accountability Act (HIPAA), which provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) used for treatment, payment, and health care operations.
HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for the use and disclosure of PHI for treatment, payment, and healthcare operations. The Notice explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this. If you have any questions, it is your right and obligation to ask so we can have a further discussion before signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless we have taken action in reliance on it.
Use and Disclosure of Protected Health Information:
● For Treatment – We use and disclose your health information internally in the course of your treatment. If we wish to provide information outside of our practice for your treatment by another healthcare provider, we will have you sign an authorization for the release of information. Furthermore, authorization is required for most uses and disclosures of psychotherapy notes.
● For Payment – We may use and disclose your health information to obtain payment for services provided to you.
● For Operations – We may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.
For HIV Disclosure- Under the Health Insurance Portability and Accountability Act (HIPAA)
Privacy Rule, public health authorities are authorized to collect and receive private health information "for the purpose of preventing or controlling disease" and in the "conduct of public health surveillance..." without patient or provider consent or authorization other than state or local public health law. This clause authorizes providers to report HIV/AIDS cases to the HIV Epidemiology Program without obtaining patient consent and it authorizes health department personnel to review medical records and any other source of information needed to report the case.
Any other disclosure of HIV-related information must be made on the "HIPAA- Compliant Authorization for Release of Medical Information and Confidential HIV-Related Information". State law prohibits any further disclosure of HIV-related private health information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
Client Rights:
● Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
● Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for payment or our operations with your health insurer. We will agree to such unless a law requires us to share that information.
● Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.
● Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
● Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and the release of information must be completed. Furthermore, there is a copying fee charge of $25.00. Please make your request well in advance and allow 2 weeks to receive the copies. If we refuse your request for access to your records, you have a right to review them, which we will discuss with you upon request.
● Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.
● Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
● Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. At your request, we will discuss with you the details of the accounting process.
● Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.
● Right to Choose – You have the right to decide not to receive services with us. If you wish, we will provide you with the names of other qualified professionals.
● Right to Terminate – You have the right to terminate services with us at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with us in session before terminating or at least contact must be made by phone letting us know you are terminating services.
● Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you.
Clinician Duties:
● We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices concerning PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will provide you with a revised notice in the office during our session.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND
AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT