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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., LLC 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 New Jersey State Board of Psychological Examiners 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. You will be provided a form on which you can list your authorized means of communication. It will understood that there may be times when you provide me with additional means to communicate outside of those listed on the form 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., LLC 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., LLC 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.
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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.  You may revoke this Agreement in writing at any time.That revocation will be binding unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred. 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. 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, 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

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

Intake session: 60 min   $190

Psychotherapy sessions: 

45 min   $160*

60 min   $190

30 min   $115

*45 minutes is the length of a standard therapy appointment

Group therapy sessions:  60 min   $90

Telephone consultations >5 minutes, prorated in 15 min increments: $200/hr

Other professional services, prorated in 15 min increments (collateral contacts, reading/sending emails, phone calls, etc.): $200/hr

No Show or Late cancellation (less than 48 hours notice): Full cost of service (e.g., $160 for a 45 minute appointment)

Expedited services requiring delivery at the last minute: $400/hr

Psychological Testing: $350+ 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 which last more than 5 minutes, reading and/or composing emails, scoring tests you may take, attendance at meetings or consultations with other professionals which you have authorized, 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 $200 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 $200 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 litigation for therapeutic and ethical reasons.  I specifically request that you do not ask me to testify in court or participate in a deposition, either in person or by affidavit.  You are to instruct your attorney not to subpoena me or to refer in any court filing to anything that has been said to you privately 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 my participation in litigation become required/ordered, you will be expected to pay for any of my professional time that is required. You should also be aware that a $2,000 retainer is required for preparation and testimony for court or a deposition of which $850 is non-refundable.  Charges will be prorated based on actual time (although $800 minimum will be charged), and may exceed the retainer amount. The hourly rate for all court/legal related matters is $300/hour.  Charges will be prorated based on actual time (although $850 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. If you anticipate that you may be involved in litigation, please discuss this with me as soon as possible so that we may review concerns and ethical issues.

Any preparation of records that requires administrative time will be billed at $100/hour.  Any preparation of records that requires my time (to review, to write a summary, etc.) will be billed at $200/hour.  If preparation of records is part of a court or legal matter, the charge is $300/hour as noted above.  In addition, any expedited services needed are charged at $400/hour as noted above.

Your appointment time is reserved exclusively for you.  As such, you must provide at least 48 hours notice to cancel an appointment and avoid charges.  You will be billed the full amount of the session scheduled (e.g., $160 for a 45 minute session) if you do not provide 48 hours notice or if you fail to arrive for your scheduled appointment.  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.  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.

There will be a $40.00 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.

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 will not be written 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 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 me 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 requires 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.-Fri.). 

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 to speak to the mental health professional on call.**

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:

         If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the doctor-patient privilege.  I cannot provide any information without your written authorization, a properly served subpoena which is not objected to on your behalf, or a court order, unless your mental health is an element of your claim or defense.  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 patient files a complaint or lawsuit against me, 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 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, 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 except for treatment summaries, provided upon request. 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. I will 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; no paper records will be kept.

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.

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, 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 and agree to its terms and 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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