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Terms and Policy

NOTICE OF PRIVACY PRACTICES
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

The Health Insurance Portability Act (HIPAA) and the Notice of Privacy Practices, is a federal law that provides you additional privacy protection and explains your rights with regard to the release of any Protected Health Information (PHI). The law requires that we obtain your signature acknowledging that you have read or have a copy of our Privacy Practices Agreement.

NOTICE OF PRIVACY PRACTICES

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Federal legislation (HIPAA) requires that all healthcare providers issue an official notice of one's privacy practices. Protected Health Information (PHI) is a term that will be used throughout this document. It refers to information in your health records that could identify you.

Uses and Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your PHI for treatment, payment, and healthcare operations purposes with your written authorization.
Treatment is when I provide, coordinate, or manage services related to your healthcare. Examples of treatment would be when I consult with another healthcare provider such as your physician or another mental health professional who is providing treatment.
Payment is when I obtain reimbursement from you for your care. Examples include when I disclose PHI to your health insurance carrier so that you may get reimbursed. I may need to send PHI such as your name, address, office visit dates, and codes identifying your diagnosis and treatment to your insurance company. Also, I may need to supply basic identifying information such as your name, address, and phone number to an attorney or billing service for collection of any outstanding payment.
Healthcare operations refer to activities that relate to the performance and operation of the practice. For example, healthcare operations include administrative services, scheduling appointments, business related matters, case management, and care coordination.

Uses and Disclosures Requiring Written Authorization
You must sign an authorization before we can release your PHI for any other issues and disclosures not described in the Privacy Notice. When appropriate written authorization is obtained, Kim Painter, Ph.D., PLLC may use or disclose PHI to others whom you designate. An authorization is permission above and beyond the general consent noted in the prior section that permits only disclosures in treatment, payment, and healthcare operations. When I ask for information outside of these parameters, I will obtain an authorization from you before releasing information. For example, you may ask me in writing to contact a school, release a report to someone, or send records after you no longer are a patient within the practice.

If you give me authorization to use or disclose information about you, you may revoke that authorization in writing at any time. However, I am unable to retract any disclosures that have already been made made in good faith with any previous written authorizations provided. Also, if authorization is obtained from you as a condition of your obtaining insurance coverage, the law provides the insured the right to contest the claim under the policy.

Psychotherapy notes may be made at the discretion of the healthcare provider. Psychotherapy notes can only be released by a written authorization from the client or a court order. I do not disclose PHI for marketing or sales. Other use and disclosures not described in the Privacy Notice will be made only with authorization from the individual (or legal guardian in case of a minor).


Uses and Disclosures Not Requiring Consent or Authorization:
I may use or disclose PHI without your consent or authorization in the following circumstances:

If you reveal information related to the abuse or neglect of a child, dependent adult, or elderly person, then the appropriate authorities may be contacted.

If you threaten bodily harm or death to yourself, I may notify the appropriate authorities and appropriate others (e.g., family member, inpatient hospital staff).

If you threaten bodily harm or death to others, I may notify the appropriate authorities and/or the intended victim.

If there is clear and imminent danger to you or the public or there is probable cause to believe that a potential victim is likely to be in danger, I may notify the appropriate authorities and/or the intended victim(s).

If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.

If there is need for healthcare oversight, the North Carolina Psychology Board has the power, when necessary, to subpoena records relevant to an inquiry or investigation.

If there are legal proceedings, patient/therapist communications are privileged except for the following:
If your mental status is an issue before the court.
If the judge authorizes a court order because he or she feels that communication is necessary to the proper administration of justice.
If a government agency is requesting information for health oversight activities, I may be required to provide it for them.
If a complaint or lawsuit is lodged against me, I may disclose relevant information regarding that patient in order to defend myself.
If you file a worker's compensation claim, I may be required to release relevant information from your mental health records to a participant in the worker's compensation case, a reinsurer, the health care provider, medical and non-medical experts in connection with the case, the Division of Worker's Compensation, or the Compensation Rating and Inspection Bureau.

When the use and disclosure without your consent or authorization is allowed under other sections of Section164.512 of the Privacy Rule and the state's confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

Patient Rights:

Right to request restrictions. You have the right to request restrictions on certain uses and disclosures of PHI to you. I am not required, however, to agree to a restriction you request.

Right to restrict. You have the right to restrict certain disclosures of PHI information to a health plan if you pay out of pocket in full for the healthcare services.

Right to request different ways to communicate with you. You have the right to request how and where I contact you about PHI. For example, you may wish to be contacted at work or utilize a different address or phone number. It will be understood that there may be times when you provide me with additional means to communicate and it will be understood that these, too, will be considered patient authorized communications. You also have the right to have records sent to you in electronic format. I am allowed to charge a fee for providing access in electronic format.

Right to a paper copy. You have the right to obtain a paper copy of the records from me upon request, even if you have agreed to receive the notice electronically or other means by which information is sent to you.

Right to inspect and copy. You have the right to see and copy both the PHI in my records and billing information that was used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances but in some cases you may have this decision reviewed.

Right to amend. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. Upon your request, we will discuss the details of the amendment process.

Right to accounting. You generally have the right to request a list of disclosures of PHI. On your written request, I will discuss with you the details of the accounting process.

Right to be notified of breach. You have the right to be notified if there is a breach of unsecured Protected Health Information.

Psychologist's Duties:
Kim Painter, Ph.D., PLLC is required by law to maintain the privacy of the PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice. I will post a notice of any changes of our Notice of Privacy Practices with the effective date in the waiting room and will have copies of the revised policy available.

Questions and Complaints:

If you have questions about this notice, disagree with a decision that I made about access to your records, believe your privacy rights have been violated, or have other concerns about your privacy rights, you may contact Kim Painter, Ph.D. You may also file a complaint with the U.S. Department of Health and Human Services.

Who will follow this notice:

Any healthcare professional authorized to enter information into your medical record, all employees, staff, and personnel at Kim Painter, Ph.D., PLLC who may need access to your information must abide by this notice. All subsidiaries and business associates of this practice must agree to maintain the privacy of any patient information they may come in contact with either advertently or inadvertently. Except where necessary, only essential medical information will be released about you.


The Effective Date of this notice: October 1, 2013.
( Type Full Name )
( Full Name )
Telepsychology Informed Consent

TELEPSYCHOLOGY INFORMATION AND CONSENT

Telepsychology is the delivery of psychological services using interactive audio and visual electronic systems where the psychologist and the patient are not in the same physical location.

The interactive electronic systems used in telepsychology incorporate network and software security protocols to protect confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption.

Potential Benefits

  Increased accessibility to psychological treatment

  Patient convenience

Potential Risks

  As with any therapy, there may be potential risks associated with use of telepsychology. I understand these risks include, but may not be limited to:

  Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate mental health decision making by Kim Painter, Ph.D., PLLC

  A lack of access to all the information that might be available in a traditional face to face visit, which may result in errors in mental health treatment.

  Telepsychology care may not be as complete as face to face care.

  Telepsychology does not decrease or minimize the risks that might be present in a mental health condition.

  The possibility (despite best efforts to prevent this) that the transmission of mental health information could be disrupted or distorted by technical failures in transmission.

  The possibility that electronic transmission of mental health information could be interrupted or even accessed illegally by unauthorized persons.

  Delays in mental health treatment may occur due to deficiencies or failures of the equipment.

  Kim Painter, Ph.D., PLLC may not be able to provide some specific types mental health treatment to me using interactive electronic equipment (such as completing rating forms in office).

  Kim Painter, Ph.D., PLLC may not be able to provide or arrange for emergency mental health care that I may require.

Confidentiality

  I understand the laws which protect the confidentiality of therapy information apply to telepsychology.

  My video telepsychology visits will not be recorded and all identifying information in the interaction will be kept secure in the same manner as any other private mental health information.

My Rights

I understand that:

  The software technology used by Kim Painter, Ph.D., PLLC is encrypted per the software company's explanation of services to prevent the unauthorized access to my private mental health information.

  I have the right to withhold or withdraw my consent to the use of telepsychology during the course of my care at any time.

  The withdrawal of my consent will not affect any future care or treatment.

  Kim Painter, Ph.D., PLLC has the right to withhold or withdraw consent for the use of telepsychology during the course of my care at any time.

  I understand that all rules and regulations, which apply to the practice of psychology in the state of North Carolina, also apply to telepsychology.

  Kim Painter, Ph.D., PLLC will inform me if any other person can hear or see any part of our session before the session begins.

  Telepsychology visits are billed at the same rate as in-office visits. I understand that my insurance reimbursement rates may be different for telepsychology visits than for in-person/in-office visits.

My Responsibilities

  I will not record any therapy sessions without written consent from Dr. Painter of Kim Painter, Ph.D., PLLC.

  I will inform Kim Painter, Ph.D., PLLC if any other person can hear or see any part of our session before the session begins.

  I understand that I, not Kim Painter, Ph.D., PLLC, am responsible for the configuration of any electronic equipment used on my computer, which is used for telepsychology sessions.

  I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.

  I understand that I must be a resident of the state of NC to be eligible for telepsychology services from Kim Painter, Ph.D., PLLC.

  I will cancel telepsychology appointments in accordance with office policies (at least 2 business days' notice) or I will be charged for the appointment time.

  I understand that charges for my appointment will be processed as they normally would for an in-office appointment.

I have read and understand the information provided above regarding telepsychology. All of my questions have been answered to my satisfaction, and I am aware of the alternatives to telepsychology including traditional face to face sessions. I hereby give my informed consent for the use of telepsychology in my mental health care and authorize Kim Painter, Ph.D., PLLC to use telepsychology in the course of my treatment. 

( Type Full Name )
( Full Name )
Good Faith Estimate/No Surprises Act

This form is being used in order to comply with the No Surprises Act/Good Faith Estimate which requires health care providers to make sure clients/patients understand costs associated with health care services.  Although all fees are outlined in Kim Painter, Ph.D., PLLC's Business Policy and Outpatient Agreement, this Act requires providers to have you sign another form indicating you understand the fees associated with the services you are seeking. 


Unlike typical medical procedures such as a surgery or scan, estimating the total cost of a course of therapy services is more nuanced.  We will discuss and decide together the general course of therapy such as frequency of appointments.  Please know that you are under no obligation to continue in therapy--you are free to discontinue therapy services at any time.  Please give us as much notice as possible (but no less than 2 business days before scheduled appointments in order to avoid charges) if you plan to discontinue treatment so that the appointment times can be offered to other clients.


FEES:

Below are Kim Painter, Ph.D., PLLC's fees (as already outlined in the Business Policy and Outpatient Agreement):


The following units of time and fees are set for professional services:

Intake session 60 min:   $225

Psychotherapy sessions:

45 min   $185 (standard therapy session)

30 min   $125

60 min   $245

Group therapy sessions 60 min:   $100

Telephone consultations, prorated in 15 min increments: $245/hr

Other professional services, prorated in 15 min increments (collateral contacts, reading/sending emails, phone calls, etc.): $245/hr

No Show or Late cancellation (less than 2 business days' notice M-F): Full cost of service

Psychological Testing: $450 per hour Varies based upon battery


In addition to appointments, charges for other professional services that you may require such as report writing, telephone conversations, reading and/or composing emails, composing letters, scoring tests you may take, attendance at meetings or consultations with other professionals, travel time to those meetings, preparation of records or treatment summaries, or the time required to perform any other service which you may request will be charged on a prorated basis of $245 per hour.  When crisis intervention is necessary, such as contacting other pertinent people (e.g., school personnel, caregivers, medical professionals), charges will be based on the $245 per hour rate.


Some families or individuals may become or are already involved in litigation.  Please note that I am unable to become involved in court-related matters and/or litigation under any circumstance, as it poses significant issues related to ethics, confidentiality, conflict of interest, and my ability to be effective in treatment.  You and/or your attorney are not to ask me to testify in court or participate in a deposition, either in person, by affidavit, or through any other means.  You are to instruct your attorney not to subpoena me, my records, or to refer in any court filing to anything that has been said in our discussions.  If you or your child believe I will be sharing what is discussed in session with attorneys and/or the court system, the effectiveness of therapy and your confidentiality will be greatly compromised.  In addition, psychologists are ethically bound not to make recommendations to the court regarding custody without having formally evaluated all parties involved.  There are forensic psychologists who provide this service to whom I can refer you if this becomes necessary. Should you act in violation of this policy and attempt to involve me in court proceedings/matters in any manner, and/or should you refuse to pay the fees for court-related involvement (or otherwise do not pay when alerted to do so), and/or should you refuse to rescind a subpoena, you agree to pay 100% of attorney fees incurred by me. In some circumstances I may need to hire my own attorney, and I/my attorney may move to quash and/or file a counter complaint for abuse of process. You will be responsible for 100% of all fees incurred by me in this process (attorney fees, filing fees, courier fees, notary fees, etc.).


While I do not participate in court-related matters under any circumstance, I am required to disclose charges for any court-related involvement.  Regardless of who initiated/requested/required participation, all time used/needed is billed to you. A $2,000 retainer is required for any court-related matter of which $1500 is non-refundable.  The hourly rate for all court/legal related matters is $500/hour.  Charges are prorated based on actual time (although $1500 minimum will be charged for court/deposition) and may exceed the retainer amount.  Please note that there are no refunds of the non-refundable retainer or any other hourly charges already incurred or reserved even if the case is settled, canceled, postponed, or continued.


Any preparation of records that requires administrative time will be billed at $100/hour.  Any preparation/review of records that requires my time (to review, to write a summary, etc.) will be billed at $245/hour.  Any expedited services or court/legal related matters are charged at $500/hour.


When you make an appointment, that time is reserved exclusively for you.  As such, you must provide *at least* 2 business days' notice (M-F) to cancel an appointment and avoid charges.  You will be billed the full amount of the session scheduled (e.g., $185 for a 45 minute session) if you do not provide 2 business days' notice or if you fail to arrive for your scheduled appointment.  If you have an appointment on a Monday, we will need notice by the Thursday before. If you have an appointment on a Tuesday, we will need notice by the Friday before.  Emails/calls over the weekend are not sufficient notice, as we will not see or be aware of the cancellation until Monday morning. It typically takes us at least 2 business days to fill cancelled appointments, and sometimes we are still unable to fill the appointment, even with that notice. Clinicians in private practice rely upon full/booked schedules for our livelihoods. Charging for late cancellations and/or no-shows is not intended to be punitive nor is it about evaluating the merit of the reason for the late cancellation or no-show; instead, it is about not having ample time to fill the appointment time with someone else and keep my clinical schedule full/booked. Please provide as much advance notice as possible if you are unable to keep your appointment in order to give others the opportunity to utilize the appointment time.  In the event of illness or inclement weather, the appointment can be changed to telehealth/phone, or for children who are too young for telehealth/phone, the appointment can be changed to a parent only session. For clients/families who book recurring appointments, please be aware that if you do not consistently attend these scheduled appointments, future sessions may be cancelled and/or rescheduled in order to allow others to utilize the appointment times. I will wait 15 minutes for you past your appointment time, but if you do not arrive within 15 minutes of your scheduled appointment time, I will assume you are not coming, and I may leave the office.  It is important to note that insurance will not reimburse for missed sessions. 


There will be a $50.00 service charge for all returned checks.


Fees will be periodically reviewed and may be increased during the course of your therapy.  Fees will be increased no more than once during any calendar year.


Following 60 days without scheduled and attended appointments, your/your child's file will be closed, and my services will be considered complete. This means that I will no longer be considered your/your child's treating and/or assessing psychologist. If services are re-engaged in the future, then the terms of this agreement will still apply, and the updated (most recent) version of this agreement will be utilized for services going forward (including updated fee schedules).


BILLING & PAYMENT

Payment for all services is due in full at each session.  In separated or divorced families, payment is due at the time of service regardless of payment agreements made between separated or divorced parents.  Services may be interrupted until payment is made. Overdue payments will be charged a 12% interest rate after 30 days.  Final payment is expected on behalf of the client before summaries or other reports, including psychological evaluations, are released. Please note that evaluation reports, treatment summaries, letters, or other requested documents will not be written or provided until the patient account has been paid in full. 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 payment. This may involve hiring a collection agency or going through small claims court, which will require me to disclose your name, address, phone number, and the amount due. If legal action is necessary, the cost and expenses of collection, including attorneys' fees, will be included in the claim.


CODES

The No Surprises Act/Good Faith Estimate requires that providers outline information such as diagnoses, common/expected codes, etc.  Dr. Painter does not diagnose individuals she has not yet met (new clients/patients).  If you are not sure what diagnosis you or your child have (current clients), please ask and we will provide you with that information.  With regard to commonly used CPT codes, please find them below.  It is possible that other codes will be used during the course of your/your child's care. 

In-person office visits: 90791 - 60 min intake code; 90834 - 45 min standard therapy code

Telehealth codes: 90791 95 - 60 min intake via telehealth; 90834 95 - 45 min standard therapy via telehealth

Testing Codes: 96130 (first hour) + 96131 (for each additional hour)


ESTIMATED TOTALS

The No Surprises Act/Good Faith Estimate requires providers to give examples of totals for services.

Estimated total cost of treatment: As mentioned above, you are under no obligation to commit to a particular course of treatment. Dr. Painter works with some clients for as little as 1-2 months and others on an ongoing basis. We will make these decisions as we work together, and if you are ever uncertain about what the costs will be, please ask and we can clarify. We strive to be very clear about charges so there are no surprises.


Total cost estimate example for therapy: If you are seeking biweekly therapy (every other week), your total charges estimate for 6 months (for example purposes only) of services would be the cost of service multiplied by the number of weeks. For example, $185 x 13 weeks (approximately 13 biweekly sessions in 6 months) = $2405. This is in addition to the cost of the intake appointment ($225) which would bring the grand total to $2630.


If you are seeking psychological evaluation services, the charges are $450 per hour and most evaluations take 6 hours to complete. Every person is different and some will take less time and some will take more time. In addition, there are charges for the intake session ($225) and the feedback session ($225). Therefore, the estimate for a psychological evaluation with 1 intake, 6 hours of testing, and 1 feedback session is: $3150.  Again, this is just an estimate example.


DISCLAIMER

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.


DISPUTE

If you are billed for more than the Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are substantially higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price(s) reflected on the Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises


The issue of dispute should not come up during the course of typical care.  Again, all fees are listed here in this No Surprises Act/Good Faith Estimate form and in the Business Policy and Outpatient Agreement.  You may discontinue services at any time (but with no less than 48 hours notice to avoid charges), and fees for services already incurred stand. 


ACKNOWLEDGEMENT

I have read and understand Kim Painter, Ph.D., PLLC's charges for services. If I have any questions, I can ask at any time. I understand these are estimates and my actual costs may be higher or lower. I also understand that I am free to discontinue services at any time (with no less than 2 business days' notice before scheduled appointments). I understand that if I request other/additional services (i.e., therapy services in addition to an evaluation, phone calls with other providers, a school observation, etc.) and/or my particular situation requires it (i.e., emergency services), I am still responsible for those charges.

( Type Full Name )
( Full Name )
Business Policy and Outpatient Agreement

Welcome to my practice! This document (the Agreement) contains important information about my 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.  Please read this document carefully, and we can discuss any questions you have. When you sign this document, it will represent an agreement between us, and it is binding.


Please note that this contract is between you and your specific provider.  Although Kim Painter, Ph.D., PLLC may share office space, referrals, and/or administrative support with other providers, each provider is their own separate business entity, and each provider is solely responsible for his/her own clinical and non-clinical decisions and services.


Psychological Services

Psychotherapy is not easily described in general statements. It varies depending on the particular problems you are experiencing. Psychotherapy is not like a medical doctor visit. Instead, it calls for active effort on your part. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, or frustration. 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.


During or after our first session or two, we will be able to discuss initial clinical impressions and therapeutic goals. You should evaluate this information along with your own assessment about whether you feel comfortable working with me.  We will also determine whether I am the appropriate psychologist for your needs. Therapy involves a commitment of time, money, and energy, so you should carefully select the psychologist you want to work with.  If you have questions, we should discuss them whenever they arise. 


Professional Fees and Appointments

The following units of time and fees are set for professional services:

Intake session: 60 min   $225

Psychotherapy sessions:

45 min   $185* This is the typical length of a therapy appointment

30 min   $125

60 min   $245

Group therapy sessions: 60 min   $100

Telephone consultations, prorated in 15 min increments: $245/hr

Other professional services, prorated in 15 min increments (collateral contacts, reading/sending emails, phone calls, etc.): $245/hr

No Show or Late cancellation (less than 2 business days' notice M-F): Full cost of service

Psychological Testing: $450 per hour; Total time varies based upon battery


In addition to appointments, charges for other professional services that you may require such as report writing, telephone conversations, reading and/or composing emails, composing letters, scoring tests you may take, attendance at meetings or consultations with other professionals, travel time to those meetings, preparation of records or treatment summaries, or the time required to perform any other service which you may request will be charged on a prorated basis of $245 per hour.  When crisis intervention is necessary, such as contacting other pertinent people (e.g., school personnel, caregivers, medical professionals), charges will be based on the $245 per hour rate.

Some families or individuals may become or are already involved in litigation.  Please note that I am unable to become involved in court-related matters and/or litigation under any circumstance, as it poses significant issues related to ethics, confidentiality, conflict of interest, and my ability to be effective in treatment.  You and/or your attorney are not to ask me to testify in court or participate in a deposition, either in person, by affidavit, or through any other means.  You are to instruct your attorney not to subpoena me, my records, or to refer in any court filing to anything that has been said in our discussions.  If you or your child believe I will be sharing what is discussed in session with attorneys and/or the court system, the effectiveness of therapy and your confidentiality will be greatly compromised.  In addition, psychologists are ethically bound not to make recommendations to the court regarding custody without having formally evaluated all parties involved.  There are forensic psychologists who provide this service to whom I can refer you if this becomes necessary. Should you act in violation of this policy and attempt to involve me in court proceedings/matters in any manner, and/or should you refuse to pay the fees for court-related involvement (or otherwise do not pay when alerted to do so), and/or should you refuse to rescind a subpoena, you agree to pay 100% of attorney fees incurred by me. In some circumstances I may need to hire my own attorney, and I/my attorney may move to quash and/or file a counter complaint for abuse of process. You will be responsible for 100% of all fees incurred by me in this process (attorney fees, filing fees, courier fees, notary fees, etc.).

While I do not participate in court-related matters under any circumstance, I am required to disclose charges for any court-related involvement.  Regardless of who initiated/requested/required participation, all time used/needed is billed to you. A $2,000 retainer is required for any court-related matter of which $1500 is non-refundable.  The hourly rate for all court/legal related matters is $500/hour.  Charges are prorated based on actual time (although $1500 minimum will be charged for court/deposition) and may exceed the retainer amount.  Please note that there are no refunds of the non-refundable retainer or any other hourly charges already incurred or reserved even if the case is settled, canceled, postponed, or continued.


Any preparation of records that requires administrative time will be billed at $100/hour.  Any preparation/review of records that requires my time (to review, to write a summary, etc.) will be billed at $245/hour.  Any expedited services or court/legal related matters are charged at $500/hour.


When you make an appointment, that time is reserved exclusively for you.  As such, you must provide *at least* 2 business days' notice (M-F) to cancel an appointment and avoid charges.  You will be billed the full amount of the session scheduled (e.g., $185 for a 45 minute session) if you do not provide 2 business days' notice or if you fail to arrive for your scheduled appointment.  If you have an appointment on a Monday, we will need notice by the Thursday before. If you have an appointment on a Tuesday, we will need notice by the Friday before.  Emails/calls over the weekend are not sufficient notice, as we will not see or be aware of the cancellation until Monday morning. It typically takes us at least 2 business days to fill cancelled appointments, and sometimes we are still unable to fill the appointment, even with that notice. Clinicians in private practice rely upon full/booked schedules for our livelihoods. Charging for late cancellations and/or no-shows is not intended to be punitive nor is it about evaluating the merit of the reason for the late cancellation or no-show; instead, it is about not having ample time to fill the appointment time with someone else and keep my clinical schedule full/booked. Please provide as much advance notice as possible if you are unable to keep your appointment in order to give others the opportunity to utilize the appointment time.  In the event of illness or inclement weather, the appointment can be changed to telehealth/phone, or for children who are too young for telehealth/phone, the appointment can be changed to a parent only session. For clients/families who book recurring appointments, please be aware that if you do not consistently attend these scheduled appointments, future sessions may be cancelled and/or rescheduled in order to allow others to utilize the appointment times. I will wait 15 minutes for you past your appointment time, but if you do not arrive within 15 minutes of your scheduled appointment time, I will assume you are not coming, and I may leave the office.  It is important to note that insurance will not reimburse for missed sessions. 


There will be a $50.00 service charge for all returned checks.


Fees will be periodically reviewed and may be increased during the course of your therapy.  Fees will be increased no more than once during any calendar year.


Following 60 days without scheduled and attended appointments, your/your child's file will be closed, and my services will be considered complete. This means that I will no longer be considered your/your child's treating and/or assessing psychologist. If services are re-engaged in the future, then the terms of this agreement will still apply, and the updated (most recent) version of this agreement will be utilized for services going forward (including updated fee schedules).


Billing and Payments

Payment for all services is due in full at each session.  In separated or divorced families, payment is due at the time of service regardless of payment agreements made between separated or divorced parents.  Services may be interrupted until payment is made. Overdue payments will be charged a 12% interest rate after 30 days.  Final payment is expected on behalf of the client before summaries or other reports, including psychological evaluations, are released. Please note that evaluation reports, treatment summaries, letters, or other requested documents will not be written or provided until the patient account has been paid in full. 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 payment. This may involve hiring a collection agency or going through small claims court, which will require me to disclose your name, address, phone number, and the amount due. If legal action is necessary, the cost and expenses of collection, including attorneys' fees, will be included in the claim.


Insurance Reimbursement

I do not participate in any managed care or insurance agreements (including Medicaid and Medicare) and am an "out of network" provider. You may wish to submit receipts of our sessions to your insurance company to seek reimbursement directly from them. You will pay in full at the time of service and your insurance company will reimburse you (not me) directly.  It is your responsibility to understand the benefits of your policy, as coverage can vary greatly.  Your insurance may or may not cover therapy or may cover a portion of the charges.  You should be aware that not all services are covered by insurance policies (e.g., school visits, telephone consultations).


You should also be aware that your contract with your health insurance company may require me to provide it with information relevant to the services I provide to you if you submit claims. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested.  If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention.  You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you.  Once the insurance company has your claim information, it will become part of the insurance company files.  Though all insurance companies claim to keep such information confidential, I have 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.  I will provide you with a copy of any report I submit, if you request it.  By signing this Agreement, you agree that I can provide requested information to your carrier.


Contacting Me

If you need to contact me outside of our scheduled appointment time, you may choose to either call or email me.  If you call and are unable to reach me immediately (I am often in session), please leave a detailed message with your contact information (even if you think I already have it).  I strive to return phone calls within 24-48 hours (Mon.-Thurs.). 


If you choose to email me, please be aware that email is not a completely secure or confidential medium of communication.  If you send me an email, I will assume that you are granting me permission to respond to you via email and that you understand the risks involved in communicating in this manner.  In addition, please use email to handle administrative matters and not for clinical matters.  Please be aware that emails sent to me cannot be guaranteed to remain private.  For example, in divorced families with joint legal custody, emails sent to me cannot be guaranteed to be kept private from the other parent. No urgent or pressing matters should be sent exclusively via email, as I cannot guarantee how often email will be checked.


**In the event of an emergency, please call 911 or go to your nearest emergency room and ask for the mental health professional on call.**


*I do not provide crisis management/on call services.*  If you anticipate needing regular contact outside of scheduled sessions, we should discuss this and possibly refer you/your child to a clinician who provides this type of service.


Limits on Confidentiality

The law protects the privacy of all communications between a patient and a therapist.  In most situations, I can only release information about your treatment to others if you sign a written authorization form that meets legal requirements imposed by HIPAA and/or North Carolina law. In the following situations, however, no authorization is required to disclose protected health information:

        Your mental status is an issue before the court.

        A judge determines/orders that communication is needed for the proper administration of justice.

        If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.

        If a patient files a complaint or lawsuit against me/Kim Painter, Ph.D., PLLC, I may disclose relevant information regarding that patient in order to defend myself.

        If there is need for healthcare oversight, the North Carolina Psychology Board has the power, when necessary, to subpoena records relevant to an inquiry or investigation.

        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 conceal the identity of the patient. The other professionals are also legally bound to keep the information confidential.  

There are some situations in which I am legally obligated to take action, and I may have to reveal some information about a patient's treatment.

        If you reveal information related to the abuse or neglect of a child, dependent or disabled adult, or elderly person, then the appropriate authorities may be contacted.

        If you threaten bodily harm or death to yourself, I may notify the appropriate authorities and appropriate others (e.g., family member, inpatient hospital staff).

        If you threaten bodily harm or death to others, I may notify the appropriate authorities and/or the intended victim.

        If there is clear and imminent danger to you or the public or there is probable cause to believe that a potential victim is likely to be in danger, I may notify the appropriate authorities and/or the intended victim(s).

With the exception of situations in which I am legally required to breach confidentiality, by signing this agreement you agree that I may use my professional judgment to determine what is and what is not shared with parents/guardians of child/minor clients.   In addition, by signing this agreement, you are waiving your right to access your or your child's treatment records. Treatment summaries can be provided upon request (time to create summaries is billed at $245/hour as previously noted). I will not share with you what your child has disclosed without your child's consent unless safety is an issue or there is a specific court order. It is standard practice for me to discuss general concerns with you, what progress is being made, and listen to your concerns/feedback.  Protecting the confidentiality of minors involved in therapy allows minors (particularly adolescents) to participate in therapy without feeling at risk of having their personal information shared with parents/caregivers and/or the court system.  In testing or assessment cases, by signing this agreement, you are waiving your right to access your or your child's testing/assessment records, including test data, except for that which is included in the report.


I use an electronic records system and records are kept digitally.


It is also my expectation and requirement that you (or anyone also present) will not record (audio and/or video) any of our conversations/meetings, either in person, on the phone, or through any other means.  *Recording of any kind is grounds for immediate termination of services.*


Social Media Policy

Due to concerns about confidentiality and privacy, I have decided to not accept friend or contact requests from current or former clients on social networking sites (Facebook, LinkedIn, etc.). Because social networking sites, such as Twitter, Instagram, Facebook, and LinkedIn, are not secure, I do not respond to messaging or wall postings from clients on these sites in order to maintain your confidentiality and my privacy.



Your signature below indicates that you have read this agreement in its entirety, and you agree to all of its terms.  Your signature below also serves as an acknowledgement that you have been provided a copy of the Notice of Privacy Practices as required by HIPAA.

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