PRACTICE INFORMATION & TREATMENT/EVALUATION PROCEDURES and PSYCHOTHERAPIST-PATIENT SERVICES AGREEMENT UNDER HIPAA (2007)
Joseph S. Busey, Ph.D., ABPP, Licensed Psychologist PSY3413; www.drjoe.com
12945 Peach Tree Lane, Red Bluff, CA 96080-7807 (530) 529-5868; fax 529-4031
_____________________________________________________________________Name, DOB, SSN
_________________________________________________________________Address, Phone, Doctor
(1) Emergencies (12) State-Required Information
(2) Fees & Hours (13) Patient Bill of Rights
(3) Overdue Accts. Collection (14) HIPAA Patient Rights
(4) Insurance Reimbursement (15) Minors & Parents
(5) Vacation Schedule (16) Releases of Information
(6) Cancellation Policy (17) California Notice of Privacy Practices
(7) Punctuality (18) Workers’ Compensation Information
(8) Telephone Calls (19) Insurance “Signature on File”
(9) Benefits, Risks, & & Assignment of Benefits
Alternatives to Treatment (20) Signature on File until Agreement Signed
(10) Limits on Confidentiality (21) Acknowledgement & Signed Agreement
(11) Professional Records
Because confidential health information leakage has been a problem (companies knowing about your health problems, hospitals giving out information about patients over the phone, much of your medical history available on computers that can be hacked) and people have been losing health coverage when they change jobs, Congress has seen fit to pass the Health Insurance Portability and Accountability Act [HIPAA]. This took effect on April 14, 2003, and like a lot of things with good intentions it can be a nightmare. This act applies to psychologists mainly if they use electronic billing, which I do not; however, I’ve been informed by my national and state psychological associations that I should follow all the guidelines because soon enough those same guidelines will be extended to small independent practices such as mine. Hence in order for me to give you treatment, you’ll have to wade through this obscenely large document and sign some things at the end of it. When you get bogged down reading it and perhaps have strong feelings about it, just think how it was for me to have to write all of this and to have to present it to you! Please know that nothing has changed from the way I normally conduct my practice; the ONLY difference is that these rules and regulations are supposedly providing more oversight and protection for you, which I hope they do. What follows is the material I have been giving patients for many years, interwoven with all the highfalutin’ legal language and stilted phraseology that the experts who dream up these things have instructed me to provide to you.
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 new federal law (with bloated bureaucracy and enough paperwork to extinguish not only Spotted Owls, but also every other sylvan avian species) that provides new privacy protections and new 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. HIPAA requires that I provide you with a Notice of Privacy Practices [the Notice] for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is included within this Agreement as Section 17, explains HIPAA and its application to your personal health information in greater detail.
The law requires that I obtain your signature acknowledging that I have provided you with this California Notice of Privacy Practices at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless: (1) I have taken action in reliance on it; (2) there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or (3) you have not satisfied any financial obligations to me you have incurred.
Please know that this huge, long document is the result of my merely following guidelines formed under the aegis of my professional associations. Had I more time and legal training, perhaps I could have distilled this down by several pages, for you’ll find some material is duplicated within the many items I’ve been advised, or required, to present to you. The enclosed information and procedures are formidable and probably will get in the way of the beginning of treatment; however, such is the ethical/moral climate, full of litigation, in which we now live. How I wish we were back in the times where we could just use a handshake. . . .
(1) EMERGENCIES
In true psychiatric emergencies, if I don’t get back to you within half a day, here are your options: (1) the Crisis Line at Tehama County Mental Health, at 527-5637; (2) Enloe Behavioral Health, at 332-4250; (3) Drs. David Wilson or Kitt Murrison in Redding, at 223-2777; (4) either of two very long-time friends/fellow practitioners in the Bay Area: Mr. Rusty Dillon at (415) 382-1299, or Dr. Paul Popper at (415) 753-8666; or (5) if all else fails and the emergency reaches critical proportions, call 911. The extended message on my answering machine also has these complete emergency instructions.
(2) FEES & HOURS
Psychotherapy and Psychological Assessment: Starting January 1, 2007, my fee is $120/clinical hour (45-50 min.), 1 clinical hour minimum, with half-clinical-hour (22-25 min.) increments thereafter. Additional professional work, such as phone calls, letters on behalf of the patient, consultations with other professionals (with your permission), preparation of records or other services you request, may be charged at this rate with no minimum. Administrative work, such as copying, may be charged at a lesser rate. Comparable fees by equally qualified and experienced practitioners in the Bay Area are now at least $140-150. If you become involved in legal proceedings that require my participation, you will be expected to pay me at the start (or we may negotiate a lien upon your settlement) for all my professional time, including preparation and travel, even if I am called to testify by another party (though the other party often picks up the tab for depositions, etc.). Because of the difficulty of legal involvement, my forensic fees are higher (see below).
Because of contractual arrangements with different insurance companies, fees for patients may vary; it is the stated intention of my office to charge the maximum fee allowable under the insurance contract. I have no sliding scale, but I do see at least 10% of my patients at reduced fee, which includes some managed-care, HMO-type companies who pay miserly for my services. Unfortunately, the waiting list for such low-fee slots is almost always several months long.
Unless advance arrangements have been made, I want payment immediately after services are rendered. If you have insurance, it is your responsibility to pay your deductible, co-payments, and any legitimate charges not covered by the insurance. In general, most patients assign their insurance benefits to me, and I wait for the company to pay me, directly. Sometimes it takes up to six months for me to get complete payment for a session, so I do demand prompt and timely payment of the co-pay and any deductible. I reserve the right to charge what the law allows for bounced checks and for interest or carrying charges for outstanding balances; however, I usually charge only what the bank charges me for bad checks ($4 or $5), and I do not normally charge interest on balances. Because of my huge paperwork load, I sometimes get behind in my financial records, so if you think I owe you money back, tell me immediately and I’ll make it top priority.
Psychological/Business Consultation: On-site Meetings are $300/clinical hour (50 min.), 1 hour minimum, with half-hour increments after 10 minutes overtime. Travel over 15 minutes each way is billed at the same rate. Office Meetings (held at my office) are $200/clinical hour, same minimum and increments. Research/Preparation is $200/clinical hour, same minimum and increments. Fees are due within 30 days.
Forensic (Legal/Court) Services: Courtroom/Deposition testimony is $300/clock hour (60 min.) 1 hour minimum, with half-hour increments after 10 minutes overtime. Legal Preparation (research, paperwork, communications) are $200/clock hour, same minimum and increments. Standby Time (on site or traveling) is $200/clock hour, same minimum and increments. Standby Time (at my own office) is $125/clock hour, same minimum, but only in hourly increments after 10-minutes overtime. All fees are due within 30 days, but some work, such as certain reports, may be withheld and not submitted until all fees are paid. Attorneys requesting my services are expected to pay the fees, themselves, and then bill their clients accordingly.
Hours: My hours are generally from 8 a.m. to 6 p.m., with two to three days per week often extending until 8 or 9 p.m. I sometimes have appointments on Saturday and occasionally on Sunday. I will always find time for emergency appointments, and I’ve been known to make house calls. Sometimes, I must on short notice reschedule patients in order to make courtroom appearances or tend to my own or my family’s medical needs. If that happens, I will make every effort to make a new appointment as soon as possible, even on weekends.
(3) OVERDUE ACCOUNTS COLLECTION
If your account has not been paid for more than 90 days after I have informed you of what you owe and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. Moreover, if such legal action is necessary, its costs will be included in the claim.
(4) INSURANCE REIMBURSEMENT
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. I will fill out forms and provide you with whatever assistance I can in helping you receive the benefits to which you are entitled; however, you (and not your insurance company) are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers; I’ll be glad to help you with this and present all the options available to you, such as seeking treatment from someone who charges less, uses a sliding scale, or who is a contracted provider for your insurance company in case I am not. (I am not contracted with some companies, such as Blue Shield or most employee assistance plans [EAPs], because their allowable amount of what someone with my education and experience can charge is, in my estimation, niggardly.)
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf.
Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. (Some managed-care plans will not allow me to provide services to you once your benefits end. If this is the case, I will do my best to find another provider who will help you continue your psychotherapy, but I am not obligated to keep treating you; hence, I seldom see people who have such plans.)
You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. Before I can disclose this information, both you and I must receive a written notification from the insurer stating what they are requesting, why they are requesting it, how long it will be kept and what will be done with the information when they are finished with it. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. 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 have given me permission to provide requested information to your insurance carrier, but remember, you can rescind this agreement in writing, which effectively ends treatment with me but keeps your record private. And of course, except in a very few rare instances (such as a psychotic or obviously paranoid patient) you can go over your record with me so see if you want to withhold what I’ve written.
Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for my services yourself to avoid the problems described above (unless it’s prohibited by contract, which is so rare I’ve never seen it).
(5) 2007 VACATION SCHEDULE
Presidents’ Day - Mon., February 19;
Easter Week - Sun., April 8 (Easter), thru Sun., April 15, returning Mon., April 16;
Memorial Day - Mon., May 28;
Fiddle Week - Sun., Jun. 17, thru Mon., Jun 25, returning Tues., June 26
July 4th Break - Tues., July 3, thru Thur, July 5, returning Fri., July 6;
Labor Day - Mon., September 3;
Africa Trip - starting mid-October thru November my family and I will travel to
Kenya to work for missionary friends; I expect to start work on
Mon., December 3; final dates of absence available by summer.
Veterans’ Day - subsumed under Africa trip;
Thanksgiving - subsumed under Africa trip
Christmas - Mon., December 24, thru Tues., January 1, returning Wed., January 2, 2008;
As always, when I go on local vacation I am available by phone within at least half a day’s time. For times away when I won’t be easily available by phone I will arrange coverage of my practice by a well-seasoned professional. Also, when at home on vacations I sometimes see patients and always see emergencies.
(6) CANCELLATION POLICY
Because the nature of psychotherapy dictates a total commitment to the process (outside of religious services, it should be the most important hour in your week), and because I schedule only one appointment per hour (instead of having people backed up in the waiting room), the full fee will be charged for any missed appointment where 24-hour advance notice was not given me (genuine emergencies excepted). Insurance and other third-party payers usually will not pay for missed appointments, so the full burden falls on the patient. In addition, if you cancel and don’t bother to reschedule a make-up appointment within the next seven days, this may be taken as tacit notice that you are terminating treatment, in which case it will be your responsibility to initiate and renegotiate re-entrance, which may mean your having to pay for the missed session.
(7) PUNCTUALITY
Please try to ring both of my doorbells at 5 minutes before the hour. I am rarely more than a few minutes behind schedule, but if I don’t answer the bell after several rings, first try the doorbell at the opposite end of the mobile home adjacent. Then, call my office number to see if I’ve left you a message. Sometimes I’m several minutes late because I’ve been to court or have made an occasional house- or hospital-call; however, when I do so, I usually leave a note on my door. If I don’t seem available, please wait anyway for at least 10-15 minutes before leaving. If power is out, come to your session anyway, for my office has emergency generator backup.
(8) TELEPHONE CALLS
For treatment and evaluation, there is generally no charge for telephone calls unless they last more than 10 minutes, in which case I reserve the right to charge my usual fee, pro-rated. Consultative and legal services phone calls that are incidental or for scheduling will not be charged; all others will be. I can usually be reached directly 5-10 minutes before the hour, unless you just want to leave a message. Since I have call waiting, many rings and no answer might occasionally frustrate you. This is not because I am talking long-windedly, for I’ll always answer call waiting, but because my answering machine is taking a call and call waiting cannot be activated by it. Merely try calling back in 60 seconds (the limit of my machine’s message taking). If there’s still a problem, call my home phone, which is listed in the White Pages of the Red Bluff directory. My cell phone number is 200-2787; however, I keep it in my car and inconsistently retrieve message from it. So if you call it and I don’t answer, you may leave a message, but you’d be smart to leave the same message at 529-5868.
(9) BENEFITS, RISKS, & ALTERNATIVES TO TREATMENT
Including this section is odious to me; however, when one looks at the legal climate of California, it is necessary; in addition, you might want to wade through the California Notice Form, Section 17 in this tedious document, which has some more items about therapy, some even actually different from those right below, and which I’m supposed to give to you.
Most people who get psychotherapy benefit at least some from the process, though success varies on the problem being addressed, the patient and his/her strengths and weaknesses, and the amount of effort expended by the patient. If you’re not willing to put in more work than I do, if you don’t want treatment success more than I do, then you probably won’t realize much benefit. Therapy requires a very active effort on your part, and self-exploration, gaining understanding, finding new ways for dealing with problems, and learning new skills are all generally quite useful. Discharging deeply felt pain and anguish is probably the most useful and longest-lasting benefit — though gaining the trust to do this sometimes takes literally years.
As in all treatments, psychotherapy is not without its risks. If done properly, therapy often brings to the surface so-called negative feelings such as anger, grief, guilt, unhappiness, frustration, and even shame. Often, the patient will become quite angry with the therapist, and if this happens, it is necessary to be honest and work it through; sometimes, the opposite happens, and the patient feels quite attracted to the therapist. Here, too, it is necessary to be honest and work it through. If a patient abruptly decides to quit, it is office policy to request one final visit to try to find reasons and iron out differences; if that doesn’t work, then referrals will be made to other therapists, if requested. Important personal decisions are sometimes made in the course of, or because of, therapy, and it is requested the patient make no important personal changes without thoroughly discussing it with me. Such changes may include, but are not limited to, exploring new or different employment options, altering substance-abuse patterns, beginning or ending relationships, or changes in schooling. Sometimes periods of loneliness happen, and suicidal feelings may briefly occur. A decision that is positive for one person in a relationship or family may not be perceived so by the other person or family members. There are no guarantees; however, commitment to the therapy process should assist in a helpful outcome.
Testing and evaluation sometimes help us understand why certain behaviors occur, and I may recommend it. Almost always, I take detailed history, and I may require each patient fill out a patient history form. We should discuss initial impressions about treatment plans, suggested procedures, and goals; we should continue to discuss them throughout the treatment. Any time you feel uncomfortable or need clarification about plans, procedures, or goals, please do not hesitate to ask. I’ll also be glad to secure appropriate consultation with another mental health professional.
(10) LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. But, there are some situations where I am permitted or required to disclose information without either your consent or Authorization:
I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).
Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.
If you are involved in a court proceeding and a request is made for information about the professional services that I have provided you and/or the records thereof, such information is protected by psychologist-patient privilege law. I cannot provide any information without: (1) your (or your legally-appointed representative’s) written authorization; (2) a court order; or (3) a compulsory process (a subpoena) or discovery request from another party to the court proceeding where that party has given you proper notice (when required), has stated valid legal grounds for obtaining PHI, and I do not have grounds for objecting under state law (or you have instructed me not to object). If you are involved in/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 pursuant to their legal authority, 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 a patient files a Workers’ Compensation claim, I must, upon appropriate request, disclose information relevant to the claimant's condition to the Workers’ Compensation insurance carrier, their case manager (if they have one), and their attorney, as well as to the injured worker’s attorney (if he/she has one) and to all health care workers treating the industrial injury or sequelae thereof.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are extremely unusual in my practice.
If I have knowledge of a child under 18 or I reasonably suspect that a child under 18 that I have observed has been the victim of child abuse or neglect, the law requires that I file a report with the appropriate governmental agency, usually the county welfare department. I also may make a report if I know or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well being is endangered in any other way (other than physical or sexual abuse, or neglect). Once such a report is filed, I may be required to provide additional information.
If I observe or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if an elder or dependent adult credibly reports that he or she has experienced behavior including an act or omission constituting physical abuse, abandonment, abduction, isolation, financial abuse, or neglect, or reasonably suspects that abuse, the law requires that I report to the appropriate government agency. Once such a report is filed, I may be required to provide additional information.
If a patient communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and contacting the police. I may also seek hospitalization of the patient, or contact others who can assist in protecting the victim.
If I have reasonable cause to believe that the patient is in such mental or emotional condition as to be dangerous to him or herself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others who can help provide protection.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems [and hopefully doesn’t scare you away], it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.
And finally, in the event group therapy services are provided, group members must remember that I cannot be held responsible for a breech of confidentiality on the part of individual group members.
(11) PROFESSIONAL RECORDS
The laws and standards of my profession require that I keep Protected Health Information [PHI] about you in your Clinical Record, which usually includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that disclosure would physically endanger you and/or others or makes reference to another person (unless such other person is a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing.
Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. I am sometimes willing to conduct this review meeting without charge. There may be a copying fee of 25 cents per page, plus for certain other expenses. If I refuse your request for access to your records, you have a right of review, (except for information supplied to me confidentially by others) which I will discuss with you upon request.
(12) STATE-REQUIRED INFORMATION (from Board of Psychology)
NOTICE: The Department of Consumer Affairs receives questions and
complaints regarding the practice of psychology. If you have any questions or
complaints, you may contact this department by calling 800-633-2322 or (916)
263-2699, or by writing to the following address: Board of Psychology, 1422
Howe Avenue, Suite 22, Sacramento CA 95825-3236."
(13) PATIENT BILL OF RIGHTS (from Board of Psychology)
“You have the right to:
· Request and receive information about the psychologist's professional capabilities, including licensure, education, training, experience, professional association membership, specialization, and limitations.
· Verify licensure of the psychologist with the Board of Psychology and receive information about any license discipline. You can do this on the Board's website at www.dca.ca.gov/psych. Click on "License Verification."
· Have written information about fees, methods of payment, insurance reimbursement, number of sessions, length of sessions, professional assistance when your psychologist is not available (in cases of vacation and emergencies), and cancellation policies before beginning therapy. This kind of information is referred to as informed consent.
· Know the limits of confidentiality and the circumstances in which a psychologist is legally required to disclose information to others.
· Receive a verbal or written treatment plan.
· Have a safe environment, free from sexual, physical or emotional abuse.
· Expect that your psychologist should not involve you in any social or business relationship in addition to your therapy relationship.
· Ask questions about your therapy or psychological assessment.
· Refuse to answer any question or disclose any information you choose not to reveal.
· Request that the psychologist inform you of your progress.
· Know if there are supervisors, consultants, students, registered psychological assistants or others with whom your psychologist will discuss your case.
· Refuse a particular type of treatment or end treatment at any time without obligation or harassment.
· Refuse or request electronic recording of your sessions, although you may request it if you wish.
· Request and (in most cases) receive a summary of your records, including the diagnosis, treatment plan, your progress, and type of treatment.
· Report unprofessional behavior by a psychologist (See section entitled "What psychologists are not supposed to do").
· Receive a second opinion at any time about your therapy or about your psychologist's methods.
· Receive referral names, addresses and telephone numbers in the event that your therapy needs to be transferred to someone else and to request that a copy or a summary of your records be sent to any therapist or agency you choose.”
(14) HIPAA PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and having the right to a paper copy of this Agreement, along with the attached Notice form (Section 17). I am happy to discuss any of these rights with you.
(15) MINORS & PARENTS
Patients under 18 years of age who are not emancipated can consent to psychological services subject to the involvement of their parent(s) or guardian unless the psychologist determines that the involvement of such parent(s) or guardian would be inappropriate. A patient over age 12 may consent to psychological services if he or she is mature enough to participate intelligently in such services, and the minor patient either would present a danger of serious physical or mental harm to him or herself or others, or is the alleged victim of incest or child abuse. In addition, patients over age 12 may consent to alcohol and drug treatment in some circumstances. However, unemancipated patients under 18 years of age and their parents should be aware that the law may allow parents to examine their child’s treatment records unless I determine that access would have a detrimental effect on my professional relationship with the patient, or to his/her physical safety or psychological well-being.
Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement is also essential, it is usually my policy to request an agreement, usually verbal, between minors over age 12 and their parents about access to information. This agreement provides that during treatment, I will provide parents with only general information about the progress of the treatment and with information about the patient’s attendance at scheduled sessions. If asked, I will also provide parents with a summary of their child’s treatment when it is complete.
Any other communication will require the child’s Authorization, unless the child is under 12 and/or unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
Where there is joint custody by separated parents/guardians I need the permission of both responsible parties to conduct asssessment/treatment, so both have to sign this agreement, unless I determine it is in the best psychological interest of the minor to keep privy from one side knowledge of assessment/treatment/progress.
(16) RELEASES OF INFORMATION
Most insurance agreements require patients to authorize me to provide to the paying company/organization certain clinical information: a diagnosis, attendance, perhaps a treatment plan or summary, or even (very rarely) a copy of the entire record. Once they have this information, I have no control over what they do with it. It also may be important for me to obtain records from any previous professional that has treated you; if so, I will request it on another form. You are entitled to receive a copy or summary of your treatment records, unless I believe that (very rarely) your seeing them would have negative consequences for you. In that case, I will provide the record(s) to an appropriate mental health professional of your choice, usually for a fee commensurate with the time spent in preparing and copying such records. In general though, I’ll be glad to go over whatever records I have on you at any time; psychotherapy sessions are not the place for secrecy!
(17) CALIFORNIA NOTICE of PRIVACY PRACTICES (regarding HIPAA)
CALIFORNIA NOTICE FORM
Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information
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. This form was designed
for HIPAA compliance under the aegis of the American Psychological Association
I. Disclosures for Treatment, Payment, and Health Care Operations
I may use or disclose your protected health information (PHI), for certain treatment, payment, and health care operations purposes without your authorization. In certain circumstances I can only do so when the person or business requesting your PHI gives me a written request that includes certain promises regarding protecting the confidentiality of your PHI. To help clarify these terms, here are some definitions:
· “PHI” refers to information in your health record that could identify you.
· “Treatment and Payment Operations”
– Treatment is when I or another healthcare provider diagnoses or treats you. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist, regarding your treatment.
– Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
– Health Care Operations is when I disclose your PHI to your health care service plan (for example your health insurer), or to your other health care providers contracting with your plan, for administering the plan, such as case management and care coordination.
· “Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
· “Disclosure” applies to activities outside of my office, such as releasing, transferring, or providing access to information about you to other parties.
· “Authorization” means written permission for specific uses or disclosures.
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. In those instances when I am asked for information for purposes outside of treatment and payment operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. (Please note that I tend not to make “psychotherapy notes.”)
You may revoke or modify all such authorizations (of PHI or psychotherapy notes) at any time; however, the revocation or modification is not effective until I receive it.
I may use or disclose PHI without your consent or authorization in the following circumstances:
· Child Abuse: Whenever I, in my professional capacity, have knowledge of or observe a child I know or reasonably suspect, has been the victim of child abuse or neglect, I must immediately report such to a police department or sheriff’s department, county probation department, or county welfare department. Also, if I have knowledge of or reasonably suspect that mental suffering has been inflicted upon a child or that his or her emotional well-being is endangered in any other way, I may report such to the above agencies.
· Adult and Domestic Abuse: If I, in my professional capacity, have observed or have knowledge of an incident that reasonably appears to be physical abuse, abandonment, abduction, isolation, financial abuse or neglect of an elder or dependent adult, or if I am told by an elder or dependent adult that he or she has experienced these or if I reasonably suspect such, I must report the known or suspected abuse immediately to the local ombudsman or the local law enforcement agency.
1) I do not have to report such an incident if:
2) I have been told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, abduction, isolation, financial abuse or neglect;
3) I am not aware of any independent evidence that corroborates the statement that the abuse has occurred;
4) the elder or dependent adult has been diagnosed with a mental illness or dementia, or is the subject of a court-ordered conservatorship because of a mental illness or dementia; and
5) in the exercise of clinical judgment, I reasonably believe that the abuse did not occur.
· Health Oversight: If a complaint is filed against me with the California Board of Psychology, the Board has the authority to subpoena confidential mental health information from me relevant to that complaint.
· Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made about the professional services that I have provided you, I must not release your information without: (1) your written authorization or the authorization of your attorney or personal representative; (2) a court order; or (3) a subpoena duces tecum (a subpoena to produce records) where the party seeking your records provides me with a showing that you or your attorney have been served with a copy of the subpoena, affidavit and the appropriate notice, and you have not notified me that you are bringing a motion in the court to quash (block) or modify the subpoena. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. I will inform you in advance if this is the case.
· Serious Threat to Health or Safety: If you communicate to me a serious threat of physical violence against an identifiable victim, I must make reasonable efforts to communicate that information to the potential victim and the police. If I have reasonable cause to believe that you are in such a condition, as to be dangerous to yourself or others, I may release relevant information as necessary to prevent the threatened danger.
· Workers’ Compensation: If you file a Workers’ Compensation claim, I must furnish a report to your employer, incorporating my findings about your injury and treatment, within five working days from the date of the your initial examination, and at subsequent intervals as may be required by the administrative director of the Workers’ Compensation Commission in order to determine your eligibility for Workers’ Compensation.
Patient’s Rights:
· Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)
· Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records 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. On your request, I will discuss with you the details of the request and denial process.
· 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. On your request, I will discuss with you the details of the amendment process.
· Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
· Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.
Psychologist’s Duties:
· I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
· I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
· If I revise my policies and procedures, I will provide you a revised notice either personally or by mail delivery.
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, please contact me directly. If you believe that your privacy rights have been violated and wish to file a complaint with me, please send your written complaint to me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I will help you find that address, if necessary.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint; however, I will defend myself by all legal means.
This notice went into effect on April 14, 2003.
I will limit the uses or disclosures that I will make as follows: the minimum disclosed necessary to preserve your privacy as much as possible while at the same time providing a high standard of care. I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice in person or by mail.
(18) Workers’ Compensation Information
A large percentage of my patients are covered under Workers’ Compensation [Workers’ Comp.] for industrial accidents or injuries that bring about the need for chronic-pain management, for treatment of stress, or some combination thereof. First of all, Workers’ Comp. patients do not themselves pay me and do not owe me for the services I provide. Either the Workers’ Comp. insurance carrier or its agent agrees to my services and pays me directly, or else the patient signs a lien (known as a Green Lien because it’s on green paper) which provides for my payment if the patient, usually through an attorney, prevails in the Workers’ Comp. administrative court proceedings (which often take place a year or two down the road, sometimes longer if the insurance carrier appeals and drags it out further; I got paid for one case three years after treatment ceased).
When I take a Green Lien I do so at my own risk, knowing that sometimes I will provide services for a year or more and not ever get paid, even though you legally owe me. However, my batting average in such cases is so high that I am willing to do this for patients who I think have a good case but are being intimidated, or in some cases perhaps bullied, by their insurance carriers (who, frankly, are just trying to save money by finding legal reasons not to pay, but who sometimes, though not too often, go overboard).
Reporting requirements for Workers’ Comp. are somewhat different than regular insurance. To get paid, I must provide reports along with my billing, and as in all legal cases, all parties involved are entitled to copies of whatever records, reports, letters, and communications are generated on the patient. Hence, by signing this Agreement in Section 21, you give approval for me to send copies of such communications to the Workers’ Comp. carrier and/or their agents, to the plaintiff (patient’s) attorney if there is one, to the defense (carrier’s) attorney if there is one, to the primary treating doctor (which every Workers’ Comp. patient must have), to the Case Manager if there is one (usually nurses hired by the carrier to oversee all phases of treatment), and to any other health professionals taking part in the treatment or assessment.
Some patients like copies of these reports, which I gladly provide — though I reserve the right to withhold this information if it is psychologically unwarranted, meaning that it might be very upsetting for the patient to see the report. (However, I think I have thus withheld such information perhaps only once in the 33 years I have been in private practice.)
[Note: the space from here until Paragraph 19 is intentionally left blank to accommodate any future verbiage that might be required as the powers at be insert themselves even further into the therapeutic process . . . .]
(19) INSURANCE “SIGNATURE ON FILE” & ASSIGNMENT OF BENEFITS
By my signature(s) below in Section(s) 20 and/or 21, I request that payment of authorized insurance/lien benefits be made on my behalf or on the behalf of:
______________________________________________________________, for whom I have fiduciary, guardianship and/or other legal responsibilities, to Joseph S. Busey, Ph.D., for any services furnished by him to me or to the above-named person(s). Under the regulations and guidelines of HIPAA I authorize any holder of medical information about me or about the above-named person(s) to release to the health insurance company and its agents any information needed to determine whether services provided are payable by the company. I understand that by my signature I am requesting that payment be made and that I am authorizing release of medical information necessary to pay the claim. If other health insurance coverage is indicated in Item 9 of the HCFA-1500 claim form or elsewhere on other approved claim forms or electronically submitted claims, my signature authorizes release of the information to the insurer or agency shown. Nothing in this agreement shall preempt contractual agreements between the undersigned and his/her health insurance company/agents.
My primary care physician is ______________________________________________________________________. I ___ do ___ do not want him/her notified I am seeing Dr. Busey for psychological aid.
(20) SIGNATURE ON FILE UNTIL AGREEMENT SIGNED
My signature directly below this paragraph (Section 20) attests that: (1) I have received a copy of this 14-page pamphlet entitled Practice Information & Treatment/Evaluation Procedures and Psychotherapist-Patient Services Agreement under HIPAA (2007), which includes as Section 17 the California Notice of Privacy Practices, and I understand not only that any questions I have will be answered in full by Dr. Busey, but also that it is my responsibility to read this pamphlet and raise to him any concerns or misunderstandings that I have; and (2) I agree that for my initial sessions/consultations, until I either sign the Agreement (Section 21, below) or cancel any future appointments, my signature directly below this current paragraph (Section 20) will serve as: (a.) an Insurance “Signature on File” so Dr. Busey can bill my insurance company, Workers’ Comp. carrier, or other responsible third party for these initial sessions and/or consultations; and (b.) if applicable, an authorized signature for a Workers’ Compensation Green Lien when Workers’ Comp. payment has been unapproved. (Other liens, as in lawsuits, are not included here, for they require an entirely different form.)
______________________________________ ______________________________________ ___________
(Printed Name) (Signature of Patient/Parent if Minor) (Date)
(21) ACKNOWLEDGEMENT & SIGNED AGREEMENT
I acknowledge that I have read the entire 14 pages of this document and have had any questions answered; furthermore, I agree to its terms and notices. Also, I have received a copy of this entire document, which includes in Section 17 the HIPAA Notice, the “California Notice of Privacy Practice (regarding HIPAA).” I consent to participate in treatment/evaluation/consultation/forensic matters, and I understand and approve that a photocopy or facsimile copy of this signed pamphlet is as valid as the original. Also, I agree the provisions in Section (20)(2)(a) and (b) are extended for the duration of my treatment with Dr. Busey. I understand that I can repeal this document, in writing, at any time, but that any action taken by Dr. Busey prior to my repealing this document will stand approved by me.
______________________________________ ______________________________________ ___________
(Printed Name) (Signature of Patient/Parent if Minor) (Date)