HIPAA FORM

Prism of Possibilities, Christine C. Cantrell PhDHIPAA/CONTRACT FORM

Christine C. Cantrell, Ph.D., LLC
Licensed Psychologist #6301009340
1026 W. Eleven Mile Road, Suite C
Royal Oak, MI 48067
248-591-2888
christineccantrellphd@gmail.com

HIPAA/CONTRACT FORM

This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA) an new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of Protected health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPAA requires that I provide you with this for your use and disclosure of PHI for treatment, payment and health care operations. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them and we can discuss any questions you may have. When you sign this document, it will also be an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it, or if you have not satisfied any financial obligations you have incurred to me.

Psychological Services

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychotherapy 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. But there are no guarantees of what you will experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue in therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

MeetingsI normally conduct an evaluation that will last from 1-3 sessions. During this time, we can both decide if I am the best person to provide the services that you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 50 minutes session per week at a time we agree on.Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. This late-cancel fee will be waived only if you and I both agree that you were unable to attend due to circumstances of a life and death nature.If possible, I will try to find another time to reschedule the session.

Professional Fees

Aetna, BCBS, Cofinity & Medicare fee schedules are set by these companies. For cash payments my fees are$200 for Intakes, $120 for individual and $140 for couple’s sessions.If you wish to cancel a session, you must give 24 hours’ notice, or you will be charged in full for the session.In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 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 me. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party. Because of the difficulty of legal involvement, Icharge $200 per hour for preparation and attendance at any legal proceeding.

Contacting Me

Due to my work schedule, I am often not immediately available by telephone. While I am usually in my office between 9 am and 9 pm, I probably will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by a confidential voice mail machine. I monitor messages frequently. I will make every effort to return your call on the same day you make it. If you are difficult to reach , please inform me of some times when you will be available and preferred phone numbers for me to call. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. You may also contactthe Common Ground Hotline at 1-800-231-1127.If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.

Limits on ConfidentialityThe law protects the privacy of all communications between a client and a psychologist. In most situations I 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 only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (PHI).

I also have business relationships with my CPA and the insurance companies listed above. As required by HIPAA, I have a formal business associate contract 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, I can provide you with the name of this CPA and a blank copy of this contract.

Disclosures required by long- or short-term disability companies or to collect overdue fees or bounced checks are discussed elsewhere in this Agreement.

If a client threatens to harm her/himself, I may be obligated to seek hospitalization for her/him, or to contact family members or others who can help provide protection.

  • There are some situations where I am 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 fore information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I 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 me to disclose information.
  • If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
  • If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. If you request that I provide information necessary for utilization review for workers’ compensation claims or short or long term disability, in order for you to receive payment for treatment from me.
  • There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a clients treatment. These situations are unusual in my practice.
  • If I have reasonable cause to suspect child abuse or neglect, the law requires that I file a report with the Family Independence Agency. Once such a report is filed, I may be required to provide additional information.
  • If I have reasonable cause to suspect the “criminal abuse” of an adult client, I must report it to the police. Once such a report is filed, I may be required to provide additional information.
  • If a client communicates a threat of physical violence against a reasonably identifiable third person and the client has the apparent intent and ability to carry out that threat in the foreseeable future, I may have to disclose information in order to take protective action. These actions may include notifying the potential victim, or if the victim in a minor, her/his parents and the county Department of Social Service) and contacting the police , and/or seeking hospitalization for the patient. If I believe that there is an imminent risk that the client will inflict serious physical harm on her/himself, I may disclose information in order to protect the client.
  • If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what I necessary.
  • While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.

Patient Rights

HIPAA provides you with several new or expanded rights with regard to your clinical records and disclosures of protected health information (PHI). These rights include requesting that I amend your record: requesting restrictions on what information from your clinical records is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to have a paper copy of this Agreement, the attached Notice form and my privacy policies and procedures. I am happy to discuss any of these rights with you.

Minors and Parents

Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. They should also be aware that patients over 14 can consent and control access to information about their own treatment, although that treatment cannot extend beyond 12 sessions or 4 months. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is also essential to successful treatment. Therefore, it is usually my policy to request an agreement from any client between 14 and 18 years old and her/his parents allowing me to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child in is in danger or is a danger to someone else, in which case I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any possible objections.

Billing and Payments

You will be expected to pay for each session at the time it is held, unless we agree otherwise. Payment schedules for professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I my be willing to negotiate a fee adjustment or payment installment plan.

If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court, or going through the county bad check program for bounced checks, which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a client’s treatment is her/his 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 a check bounces, the client will pay the provider’s bank charges of $15 per check.

Insurance Reimbursement

I only bill Aetna, BCBS, Cofinity and Medicare insurance companies directly. If you would like to use any other insurance, you will pay me up front and I will give you a special receipt that you may submit to your insurance company. This may mean that you will only qualify for out of network reimbursement rates. I will help you fill out any forms that you may receive from your insurance plan. If you want to file for workman’s compensation, long or short term disability, I will help you in obtaining authorization for you to receive reimbursement from the insurance company, but you will still pay for treatment up front.

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. Your confidentiality cannot be guaranteed with managed care, so I will help you find another provider who will help you continue your psychotherapy if you require use of your insurance plan for therapy.

You will have the opportunity to sign an acknowledgement of this contract in your electronic record, maintained by Dr. Cantrell.

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