OFFICE POLICIES, GENERAL INFORMATION & INFORMED CONSENT
Welcome to the Changing Tides Trauma Resolution practice. This form provides you the client with information that is additional to that described in the Notice of Privacy Practices. Please review carefully before signing and ask any questions you may have. Once you have signed the document, it forms an agreement between you and your therapist. You will note that the office in which we meet is shared by other clinicians. We are not a group practice, and are each sole proprietors of independent businesses. However, we have signed agreements with one another to maintain the privacy of our own and the other’s clients for your protection.
The Process of Therapy: Psychotherapy requires your very active involvement, honesty, and openness in order to address and/or change your thoughts, feelings, and behaviors. Attempting to resolve issues that brought you to therapy may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed negatively by another. During the course of therapy, your therapist is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his or her assessment of what will best benefit you. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, or my expertise in employing them, please ask and you will be fully answered.
Confidentiality: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your consent, usually in writing, except where disclosure is required or permitted by law. As indicated in the HIPPA agreement, suspicion of child abuse or neglect, and suicidal or homicidal intent are considered required by law to report. Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation or court proceeding, the defendant may have a right to obtain the psychotherapy records and/or testimony by your therapist (please note that there is a charge a separate fee for court testimony). In couples and family therapy, or when different family members are seen individually, confidentiality and privilege do not necessarily apply between couples or among family members. The therapist will use his or her clinical judgment when revealing information.
Confidentiality of e-mail, cell phone, mail, phone and faxes communication: It is very important to be aware that email and cell phone communication can be relatively easily accessed by unauthorized persons, and hence, the privacy and confidentiality of such communication can be compromised. For this reason, I caution you against unsecure email as a means of communication with clients. If I receive an email from you I will respond, but be aware of the consequences, and the fact that another person may read your emails, especially if you email from a work account. You may leave me a confidential voice mail at any time. I check my voice mail during regular business hours, which are Monday through Friday, 9am to 3pm. Please do not use fax, email or voicemail for emergencies. If you elect to communicate with me by email at some point in our work together, please be aware that email is not completely confidential. All emails are retained in the logs of your and my internet service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you, will be printed out and kept in your treatment record.
Social Media: I do not use social media as a form of therapeutic communication. I do occasionally suggest an iphone or android application that you might find helpful. These can include journal entries that you send to me via email. These are not confidential documents, and you should be aware that I am not able to maintain your confidentiality should someone be able to hack into your accounts or otherwise access your information through these apps. Parents, I sometimes shared these app suggestions with your teens, please discuss the possibility with me.
Emergencies: If there is an emergency during our work together, or I become concerned about your personal safety, the possibility or your injuring yourself or another person, I will do whatever I can within the limits of the law to ensure you receive the proper medical care. For this purpose, I may also contact the person whose name you have provided on the biographical sheet under the category of “emergency contact’.
General Emergency Procedures: If you need to contact me between appointments, please leave a message with the answering machine at 903-7880 and your call will be returned as soon as possible. I generally check my messages at least once a day. However there may be times when I do not receive your message or am unable to return your message on the same day you leave it. If an emergency situation arises, please indicate that clearly on your message, but follow up to a call with the emergency services. Since I do not provide 24-hour crisis coverage, both you and I need to be comfortable with your situation and circumstances in regards to this arrangement. There is crisis coverage available city-wide, and, if this seems appropriate for you, then we can engage in a therapeutic relationship. If you need to talk to someone right away, do not wait for a return call from me, but contact the 24-hour crisis line at 563-3200 or the Police at 911.
Office Hours: I am generally in the office 9am to 3pm Monday through Friday, and am unable to return phone calls or to check messages on the days that I am not in the office. Please leave your non-urgent message on the office phone and expect a call within 48 hours. I do travel frequently to attend/provide trainings, and may be out of the office up to a week at a time when I am unavailable for contact.
Dual Relationships: Not all dual relationships are unethical or unavoidable. I will assess carefully before entering into any type of dual relationship with clients. Anchorage is a small town and many clients know each other and/or myself from the community. Consequently you may encounter someone you know in the waiting room. Please respect the privacy of others, as you would wish your privacy to be respected. I will never acknowledge a therapeutic relationship without your permission. Generally I will smile, nod, or say hello to you in public if we pass. Please notify me if this is uncomfortable or if you would prefer I not acknowledge you at all in public. If I know you outside of the therapy office, prior to engaging in a therapeutic alliance, I will discuss with you the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. It is your responsibility to communicate to me if the dual relationship becomes uncomfortable for you in any way. I will always listen carefully and respond accordingly to your feedback. I will discontinue the dual relationship if I find it is interfering with the effectiveness of the therapeutic process or your welfare, and, of course, you may do the same at any time.
Termination: As set forth above, after the first couple of meetings, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I am not a good fit for, or for whom I am not able to provide the quality or type of services required. I will tell you honestly if I feel another therapist may be a better match for you. If at any point during psychotherapy, I assess that I am not effective in helping you reach your therapeutic goals, I will discuss it with you and, if appropriate, make another referral for treatment. If you threaten or actually harm myself or any of my loved ones or other persons in my office, you will be terminated from therapy.
Cancellations: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours (1 business day) notice is required for re-scheduling or cancelling of an appointment.
This office does provide optional reminders by email, text, or phone call. It is your responsibility to keep your scheduled appointment. If you know that you will be unable to keep your appointment, kindly provide a minimum of 24 hours notice. All missed appointments and appointments that are cancelled with less than 24 hours notice will be charged the full fee. Insurance generally does not pay for missed appointments. All missed appointments must be paid prior to scheduling another appointment time.
If I have to cancel an appointment that we have scheduled, I will make reasonable attempt to reschedule you as soon as possible. It is my intention to end all sessions and phone calls at the scheduled time (appointments are generally 45 minutes in length), and to be available for you at our scheduled appointment time. However, given the nature of therapeutic work, there are times that I will be required to go over the scheduled time with another client, which could run into the time that we had scheduled. Please know that in the event of need, I will do the same for you.
Billing and Other Office Duties: I may have someone on contract to assist with billing, filing, or other paperwork. If this occurs, the person hired will sign a business associate’s agreement that requires the highest level of confidentiality, thus protecting your privacy. Currently my biller is Renna Stevens. You can reach her at rstevens@rasbillingcom or 907-854-1476. All other individuals who work or volunteer in this building, even if not a part of my office staff, are required to sign this same agreement. This ensures your confidentiality in the event that someone working in the building should see you before or after appointment times, or otherwise hear or see confidential information inadvertently. There are a number of safeguards in place, however, to prevent this from occurring in the first place, including double-locked file keeping practices, confidential voice mail, etc. Please inquire if you have any concerns related to this issue.
Legal Proceedings (Custody Involvement, etc): Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is strongly suggested that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client), nor your attorney, nor anyone acting on your behalf call on me to testify in court or at any other proceeding, nor request a copy of the psychotherapy records. This action can be particularly harmful to children who believe they are sharing information in a safe place that is then revealed in court. Court testimony can and often does damage a child’s trust in their therapist and usually ensures that at least one parent - generally the one that the child expresses the most anger, discomfort, or difficulty with - will believe that I am not doing a good job with the child. A therapist and a child custody evaluator are not the same thing and should not be treated as such. If I am requested or subpoenaed to court on your behalf, please note that I charge a $700.00 flat fee and $300.00 per hour for court appearances/testimony, with a
$1000.00 minimum. This fee will be assessed if I am scheduled for court on your behalf, and is not contingent upon my actual participation or testimony. This fee is based on current client contract fees, and is not an expert witness fee.
Mediation and Arbitration: All disputes arising out of or in relation to this agreement to provide psychotherapy or educational services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of you (client) and I (therapist). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Anchorage in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, I can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.
Payments and Insurance Reimbursement: Clients are expected to pay the standard fee of $280.00 per initial intake assessment. Individual psychotherapy sessions are charged at $150.00 per 45 minute hour, group is $95.00 per hour and a half, and family/couples sessions are $165.00 per hour. 20-30 minute individual sessions are $90.00, case management is $150.00 per hour, and 80-90 minute sessions are $195.00 per hour. All letter/report writing, travel, etc. is $35.00 per 15 minutes. You will be provided with a “superbill” that you can present to your insurance company if you so desire. If you prefer that I bill insurance for you, please note that you remain responsible for the full fee regardless of whether or how much your insurance pays. I expect that your estimated co-pay is recovered at the time of your appointment.
Extended phone conversations (over 15 minutes), report writing, report reading, consultation with other professionals, treatment team meetings, care coordination, travel time, etc., will be charged at $35.00 per 15 minutes unless indicated and agreed upon otherwise. Insurance companies do not generally pay for these services.
Payment is expected at the time of service. If I am courtesy billing your insurance company for you, your portion of the payment will be due at the time of service, or, if you prefer, I will send you a monthly bill via encrypted email. You can pay this bill in person, via check or credit card, use the credit card authorization form given to you at intake, use the paypal button on my website at www.kimberolsonlcsw.com or pay in cash. If your account becomes more than 60 days past due, a payment plan must be established. Any overdue bills will be charged 2% per month interest after 60 days. If after 90 days the account continues to be delinquent and you have made no effort to establish a payment plan or to abide by the payment plan, I reserve the right to discontinue services, and your account may be turned over to a collection agency.
Fees are subject to change with two weeks prior notification.
Clients who carry insurance are asked to kindly remember that professional services are rendered and
charged to the client and as such you will be ultimately responsible for the full payment of services rendered in the event that your insurance company denies any claim or reimbursement. As was indicated in the section, Health, Insurance, and Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries with it a certain amount of risk. Not all issues/concerns/problems which are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. It is possible that preauthorizing with your insurance company will result in a higher reimbursement rate or more therapy sessions. Please contact your insurance company prior to or directly after our first meeting if you have not already done so, to verify the specifics of your coverage.
Signature: _________________________________________ Date: __________________________
HIPAA NOTICE OF PRIVACY PRACTICES
I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
II. IT IS OUR LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or noted by this company that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy procedures. This Notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this Notice.
Please note that I reserve the right to change the terms of this Notice and my privacy policies at any time as permitted by law. Any changes will apply to PHI already on file with me. Before I make any important changes to my policies, I will immediately change this Notice and post a new copy of it in my office and on my website. You may also request a copy of this Notice from me, or you can view a copy of it in my office or on my website, which is located at (www.kimberolsonlcsw.com).
III. HOW I WILL USE AND DISCLOSE YOUR PHI.
I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples.
A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. I may use and disclose your PHI without your consent for the following reasons:
1. For treatment. I can use your PHI within my practice to provide you with mental health treatment, including discussing or sharing your PHI with my trainees and interns. I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI to her/him in order to coordinate your care.
2. For health care operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples: Quality control - I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws.
3. To obtain payment for treatment. I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.
4. Other disclosures. Examples: Your consent isn't required if you need emergency treatment provided that I attempt to get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI.
B. Certain Other Uses and Disclosures Do Not Require Your Consent. I may use and/or disclose your PHI without your consent or authorization for the following reasons:
1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.
2. If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.
3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.
4. If disclosure is compelled by the patient or the patient's representative pursuant to California Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.
5. To avoid harm. I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public (i.e., adverse reaction to meds).
6. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.
7. If disclosure is mandated by the Alaska Child Abuse and Neglect Reporting law. For example, if I have a reasonable suspicion of child abuse or neglect.
8. If disclosure is mandated by the Alaska Elder/Dependent Adult Abuse Reporting law. For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.
9. If disclosure is compelled or permitted by the fact that you tell me of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.
10. For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, I may need to give the county coroner information about you.
11. For health oversight activities. Example: I may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.
12. For specific government functions. Examples: I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.
13. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.
14. For Workers' Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws.
15. Appointment reminders and health related benefits or services. Examples: I may use PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options, or other health care services or benefits I offer.
16. If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.
17. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance with HIPAA regulations.
18. If disclosure is otherwise specifically required by law.
C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.
D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, I will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that I haven't taken any action subsequent to the original authorization) of your PHI by me.
IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
These are your rights with respect to your PHI:
A. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in my possession, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request. Under certain circumstances, I may feel I must deny your request, but if I do, I will give you, in writing, the reasons for the denial. I will also explain your right to have my denial reviewed.
If you ask for copies of your PHI, I will charge you not more than $.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.
B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that I limit how I use and disclose your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make.
C. The Right to Choose How I Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience. I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.
D. The Right to Get a List of the Disclosures I Have Made. You are entitled to a list of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the previous six years unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.
E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone other than me. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.
F. The Right to Get This Notice by Email. You have the right to get this notice by email. You have the right to request a paper copy of it, as well.
V. HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about my privacy practices, I will take no retaliatory action against you.
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact the Clinical Director at: [Kimber Olson, 2600 Denali Street, Suite 606, 907-903-7880 or firstname.lastname@example.org].
VII. NOTIFICATIONS OF BREACHES
In the case of a breach, I am required to notify each affected individual whose unsecured PHI has been compromised. Even if such a breach was caused by a business associate, your therapist is ultimately responsible for providing the notification directly or via the business associate. If the breach involves more than 500 persons, OCR must be notified in accordance with instructions posted on its website. Your therapist bears the ultimate burden of proof to demonstrate that all notifications were given or that the impermissible use or disclosure of PHI did not constitute a breach and must maintain supporting documentation, including documentation pertaining to the risk assessment.
VIII PHI AFTER DEATH
Generally, PHI excludes any health information of a person who has been deceased for more than 50 years after the date of death. Your therapist may disclose deceased individuals' PHI to non-family members, as well as family members, who were involved in the care or payment for healthcare of the decedent prior to death; however, the disclosure must be limited to PHI relevant to such care or payment and cannot be inconsistent with any prior expressed preference of the deceased individual. If there is someone you do NOT wish to have your information after your death, please identify that individual/individuals here: ____________________________________________
If there is someone you wish to identify as the holder of your records after your death, please identify that individual here: __________________________________________
IX. Individuals' Right to Restrict Disclosures; Right of Access
To implement the 2013 HITECH Act, the Privacy Rule as amended your therapist is required to restrict the disclosure of PHI about you, the patient, to a health plan, upon request, if the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law. The PHI must pertain solely to a healthcare item or service for which you have paid the covered entity in full. (OCR clarifies that the adopted provisions do not require that covered healthcare providers create separate medical records or otherwise segregate PHI subject to a restrict healthcare item or service; rather, providers need to employ a method to flag or note restrictions of PHI to ensure that such PHI is not inadvertently sent or made accessible to a health plan.) The 2013 Amendments also adopt the proposal in the interim rule requiring your therapist, to provide you, the patient, a copy of PHI to any individual patient requesting it in electronic form. The electronic format must be provided to you if it is readily producible. OCR clarifies that your therapist must provide you only with an electronic copy of their PHI, not direct access to their electronic health record systems. The 2013 Amendments also give you the right to direct your therapist to transmit an electronic copy of PHI to an entity or person designated by the you. Furthermore, the amendments restrict the fees that your therapist may charge you for handling and reproduction of PHI, which must be reasonable, cost-based and identify separately the labor for copying PHI (if any). Finally, the 2013 Amendments modify the timeliness requirement for right of access, from up to 90 days currently permitted to 30 days, with a one-time extension of 30 additional days.
Most uses and disclosures of psychotherapy notes, marketing disclosures and sale of PHI do require prior authorization by you, and you have the right to be notified in case of a breach of unsecured PHI.
XI. EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on September 19, 2013
I acknowledge receipt of this notice
Patient Name: ________________________ Date:________Signature: __________________________
Patient Name: _________________________ Date: _______Signature: __________________________
When you need to contact your therapist for any reason, these are the most effective ways to get in touch in a reasonable amount of time:
· By phone. You may leave messages on the voicemail, which is confidential.
· By text message (see below for details.)
· By email (see below for details.)
· By the secure contact page on the website (www.therapyappointment.com).
· If you wish to communicate with me by normal email or normal text message, please read and complete the Consent For Non-Secure Communications form included with these office policies.
Please refrain from making contact with me using social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I am not prepared to watch them closely for important messages from clients.
It is important that we be able to communicate and also keep the confidential space that is vital to therapy. Please speak with me about any concerns you have regarding my preferred communication methods.
I may not be able to respond to your messages and calls immediately. For voicemails and other messages, you can expect a response within 48 hours (weekends are excepted from this timeframe.) I may occasionally reply more quickly than that or on weekends, but please be aware that this will not always be possible.
Be aware that there may be times when I am unable to receive or respond to messages, such as when out of cellular range, internet service, on vacation, or out of town.
If you are ever experiencing an emergency, including a mental health crisis, please call 911 or the city-wide crisis line at 907-563-3200
If you need to contact me about an emergency, the best method is:
· By phone
· If you cannot reach me by phone, please leave a voicemail and follow up by contacting the appropriate crisis line at 911 or 907-563-3200.
· Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole method of communicating with me in emergencies.
CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
AUTHORIZE: Changing Tides Child and Enrichment Center, LLC
TO TRANSMIT THE FOLLOWING PROTECTED HEALTH INFORMATION RELATED TO MY HEALTH RECORDS AND HEALTH CARE TREATMENT: