Please read this form carefully and sign on the last page. By signing you are agreeing to my policies and business practices. I. Informed Consent You understand that records and information collected about you will be held and released in accordance with state laws regarding confidentiality and privilege of such records and information. You understand that state and local laws require that a psychologist report all cases of abuse or neglect of minors, and the existence of a clear danger to self or others. You understand that the first session is considered a diagnostic evaluation. At this first session we will discuss your presenting problems, history, previous therapy, medications, goals, etc. This thorough evaluation will permit me to create a treatment plan for you, which will help guide our work. II. Fees Individual Psychotherapy (45 minutes) $225 I participate in some BC/BS PPO insurance plans. I honor the fee structures set by these plans. If you are unsure if I participate with your plan, it is your job to contact the insurance company and obtain the information. III. Change in Insurance It is your responsibility to notify your therapist of any changes to health insurance immediately. IV. Payment Payment is expected at the time services are rendered. I accept cash, checks and Zelle. If you wish to pay for services on a monthly basis, this can be discussed during our initial evaluation. At the end of each month, I will give you a billing statement. It will show the dates of our meetings, the charges for each, how much has been paid, and how much (if any) is still owed. If you think you may have trouble paying your bills on time, please discuss this with me. If you have an unpaid balance, I will notify you. Please inform me if financial difficulties arise, so that I may try to work out a plan that permits you to receive your therapy without excessive hardship. If you fail to honor the payment obligations that we agree upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency. Some insurance companies send the check to you. In such a case, you agree to bring the insurance check in promptly. V. Cancellation/Missed Sessions Policy Late cancellations or missed appointments are charged the full fee. Occasionally illness or emergencies occur that are beyond your control. Therefore, I allow one missed / late cancellation session. Otherwise, you must provide me with 24-hour cancellation notice, or you must pay the full fee for your session. Your insurance will not pay for any of these charges. VI. Policies Regarding Phone and Email I do not charge for time spent on the phone or email for the discussion of any procedural matters such as appointment schedules and issues regarding insurance companies. I do charge for phone time spent on therapeutic issues, at the pro-rated rates listed above. Also, time spent communicating to others on your behalf, either by phone or in writing, is also charged accordingly. I do not use Email as a communication method for therapeutic issues, since emails are an unsecure form of communication. VII. Insurance Billing I submit the in-network insurance claims on your behalf. Claims are filed electronically, whenever possible. VIII. Policies Regarding Insurance Companies If you plan to utilize your health insurance to make full or partial payment for psychological services, your insurance carrier may require that certain information about you, your problems, and your treatment be provided to them. Your insurance carrier then determines whether additional psychological treatment is needed. I will explain the requirements of your particular insurance carrier and obtain separate authorization from you for the release of such treatment plans. You may refuse to release such information to your insurance carrier. However, if you do refuse, your insurance carrier will likely refuse to make payment for additional services. You have the right to continue in treatment at your own expense. IX. The Health Insurance Portability and Accountability Act (HIPAA) The health Insurance Portability and Accountability Act (HIPAA) is a Federal Law that has been implemented to protect health services consumers. The provisions of this law, as privacy, confidentiality content disclosure and reporting, are congruent with state laws already carried out by this practice. These policies will continue and are also required by HIPAA. The privacy of your health information is protected by appropriate procedures and policies and follow official rules of consent and disclosure. For example, your records are available to you but disclosed to others only with your permission, unless disclosure is required by law. Also, there is protection of your confidential information by keeping records in secure places. Cooperation will be extended in the appropriate processing and transmission of forms, such as the provision of correct procedural and diagnostic codes. Please sign this form to indicate that you have received the information in sections I through VIII and that you understand your rights as a recipient of health services under HIPPA guidelines. Enter Email Address