Insurance Company Assigment and Release:
I, the undersigned, do hereby assign directly to Kristen Holt, LCMHC all medical benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by my insurance(s) for myself or any of my dependents. I hereby authorize release of all information necessary to secure payment of benefits (patient identifying information: name, date of birth, address, dates of service, description of service and diagnoses). I authorize the use of my signature on all insurance claim submissions for myself or my insured dependents.
Authorization for Treatment and Financial Responsibility:
I, the undersigned, do hereby give authorization to Kristen Holt, LCMHC to evaluate and treat. I also accept full financial responsibility (regardless of insurance payment or non- payment) for all charges incurred by myself or any person(s) I am responsible for i.e.; minor child, foster child, grandparent, spouse, other. Account balances must be cleared (no balance due) prior to another appointment being scheduled unless prior arrangements have been made.
Patients are requested to give notice as soon as possible when cancelling or rescheduling an appointment for the appointment slot to be available for someone else. Appointments cancelled with less than 24 hours’ notice or missed appointments will be charged a fee between $50-$100 depending on the appointment type and number of previously missed appointments. If a patient has an excess number of missed appointments or late cancellations he/she may be dismissed as a patient from the practice. An after-hours voicemail is provided for cancellations. By signing below, I agree to the appointment policy and agree to pay any fees from missing my or my dependent’s appointment, and to have such fees cleared before the next scheduled appointment.
Communication with Referring Provider: I, the undersigned do hereby give authorization to the staff of Kristen Holt’s office to provide my referring provider with confirmation of receipt of the referral, appointment dates, and notes from visits related to treatment; in addition to authorizing communication through a secure method between my referring provider and Kristen Holt’s staff.
I release to Kristen Holt, LCMHC, the above confidential information and authorization to use this information for billing and insurance claims as well as notification to other providers, when indicated. I will pay Kristen Holt, LCMHC any charges not covered by insurance. I understand that they file my insurance as a courtesy. It is solely my responsibility to know what my insurance covers. I understand I will be charged for missed appointments when not canceled within 24 hours in advance unless otherwise agreed upon.
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. 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 attached to this Agreement, 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 information. Although these documents are long and sometimes complex, it is very important that you read them carefully before signing. 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 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.
Counseling is not easily described in general statements. It varies depending on the personalities of the clinician and patient, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. In addition to cognitive behavioral therapy, I utilize person centered therapy, for trauma, eye movement desensitization and reprocessing (EMDR). Counseling is not like a medical doctor visit. Instead, it calls for a very 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. If you are a client’s guardian or caregiver you are expected to participate in the therapeutic process and give me ongoing updates on your child’s progress and response to treatment.
Counseling can have benefits and risks. Since psychotherapy often involves discussing unpleasant aspects of your life, you or your child may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. 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. There are no guarantees about what you will experience, but it is my hope that our time together will be helpful for you.
Our first few sessions will involve an evaluation of your needs or those of your child. By the end of the this period, I will be able to offer you some first impressions of what our work will include and treatment goals to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinion of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to refer you to another mental health professional.
During the first couple sessions, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If counseling is begun, I will usually schedule one 60-minute session (one appointment hour of 60 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay a late cancel/no show fee of $50 unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions and last minute cancellations cannot be filled. If it is possible, I will try to find another time to reschedule the appointment during that week. After three missed sessions, I will discuss a referral to another provider or you may be placed on my waiting list and a client from my waiting list will be brought into the practice.
My fee for initial assessment is $150.00. My hourly fee is $125.00. Payment is to be rendered the day of the appointment. In addition to weekly appointments, I charge this amount for other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services include letters, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. Specifically, letters and phone calls over 15 minutes, will result in a $25 fee. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time at $250/hr, including preparation and transportation costs, even if I am called to testify by another party or required to appear under legal subpoena.
Due to my work schedule, I am often not immediately available by phone. When I am unavailable, my cell phone is answered by voicemail. I will make every effort to return your call/text within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. If you are unable to reach me, and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the mental health professional on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a clinical social worker. 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 HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
● 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 Policies and Practices to Protect the Privacy of Your Health Information).
● You should be aware that I may contract with administrative staff. I may need to share protected information with these individuals for administrative purposes such as scheduling, billing or Quality Assurance. I also may share some clinical information for training purposes. All staff and students/trainees/supervisees have received training either here or other agencies about protecting your privacy and have agreed not to release any information without a HIPAA compliant authorization. You may elect to not allow trainees/supervisees or students to be in therapy sessions, if you wish. These practice participants also sign a HIPAA Business Associate Agreement with me, outlining their duties and obligations related to your PHI.
● Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
● If I believe that a client presents an imminent danger to his/her health or safety, I may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.
There are some situations where I am permitted or required to disclose information without either your consent or Authorization:
● If you are involved in a court proceeding and a request is made for information concerning the professional services that I provided you, such information is protected by the counselor-patient privilege law. I cannot provide any information without your written authorization, or a court order. If you are a parent involved in a custody case and requesting information regarding a minor child, I require consent of both parents (if possible) or a court order to release information. 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 a patient files a workers compensation claim, and my services are being compensated through workers compensation benefits, I must, upon appropriate request, provide a copy of the patient’s record to the patient’s employer or the North Carolina Industrial Commission.
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 unusual, but do occur and are mandated by law.
● If I have cause to suspect that a child under 18 is abused or neglected, or if I have reasonable cause to believe that a disabled adult is in need of protective services, the law requires that I file a report with the County Department of Social Services. Once such a report is filed, I may be required to provide additional information.
● If I believe that a client presents an imminent danger to the health and safety of themselves or another, I may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police.
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, 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.
CLIENT EMAIL/TEXTING INFORMED CONSENT
Risk of using email/texting - The transmission of client information by email and/or texting has a number of risks that clients should consider prior to the use of email and/or texting. These include, but are not limited to, the following risks:
● Email and texts can be circulated, forwarded, stored electronically and on paper, and broadcast to unintended recipients.
● Email and text senders can easily misaddress an email or text and send the information to an undesired recipient.
● Backup copies of emails and texts may exist even after the sender and/or the recipient has deleted his or her copy.
● Employers and on-line services have a right to inspect emails sent through their company systems.
● Emails and texts can be intercepted, altered, forwarded or used without authorization or detection.
● Email and texts can be used as evidence in court.
● Emails and texts may not be secure and therefore it is possible that the confidentiality of such communications may be breached by a third party.
Conditions for the use of email and texts - Therapist cannot guarantee but will use reasonable means to maintain security and confidentiality of email and text information sent and received. Therapist is not liable for improper disclosure of confidential information that is not caused by Therapist’s intentional misconduct. Clients/Parent’s/Legal Guardians must acknowledge and consent to the following conditions:
● Email and texting is not appropriate for urgent or emergency situations. Provider cannot guarantee that any particular email and/or text will be read and responded to within any particular period of time.
● Email and texts should be concise. The client/parent/legal guardian should call and/or schedule an appointment to discuss complex and/or sensitive situations.
● All email will usually be printed and filed into the client’s medical record. Texts may be printed and filed as well.
● Provider will not forward client’s/parent’s/legal guardian’s identifiable emails and/or texts without the client’s/parent’s/legal guardian’s written consent, except as authorized by law. ● Clients/parents/legal guardians should not use email or texts for communication of sensitive medical information.
● Provider is not liable for breaches of confidentiality caused by the client or any third party. ● It is the client’s/parent’s/legal guardian’s responsibility to follow up and/or schedule an appointment if warranted.
The laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others or the record 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, 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. In most circumstances, I am allowed to charge a copying fee of $0.10 per page (and for certain other expenses). If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
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 the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you. In addition, privacy laws and ethical guidelines prevent me from acknowledging our therapeutic relationship during a chance meeting in public. Therefore, you would need to initiate any contact in a public setting.
MINORS & PARENTS
Clients under 18 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. During treatment, I try to provide parents with general information about the progress of the child’s treatment, but do include parents as much as possible in therapy sessions. If I feel that the child is in danger or is a danger to someone else, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible and if he/she is 14 or over, and do my best to handle any objections he/she may have.
REGISTERING A COMPLAINT
If you wish to file a complaint against a North Carolina licensed professional counselor, you may do so by placing that complaint in writing and sending it to the NCCLMHC. According to the American Counseling Association’s Ethical Guidelines, you should first attempt to resolve your complaint with the counselor directly. If this is not successful, you may place your concern in writing citing the ACA Ethical Codes you believe to have been broken, and submit along with a completed NCCLMHC Complaint Form. The board will assign your complaint a number so no names will be known to anyone, but the board attorney, administrator, and ethics chair. Once the complaint has been received, notification is sent to the counselor against which the complaint was filed allowing him/her to respond to the alleged charges. If necessary, the board will investigate the complaint and issue a ruling after gathering all necessary information. Investigations will not be made unless complaints are in writing and signed by the complainant.
The contact information for the NC LCMHC Board is as follows: PO BOX 77819, Greensboro, NC 27417. The phone number is (844) 622-3572 or (336) 217-6007, and the fax number is (336) 217-9450.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. I accept cash and credit card as payment. 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 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.
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 (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.
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 healthcare, 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.
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. 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 agree that I can provide requested information to your carrier.
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.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.