GAD-7

Dear Client,

Restoration Center Chicago (hereinafter referred to as RCC) takes great care to protect your privacy. Below, you will find a government-mandated notice delineating your rights as a client. Your signature will indicate that you have received this notice. Any questions about this notice can be directed to the President of RCC, Dr. Samantha Lussier, Psy.D. at 312-548-9051.

Notice of 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.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

RCC may use or disclose your protected health information (PHI), for treatment, payment, and health care operations including purposes with your written authorization. To help clarify these terms, here are some definitions:

• PHI refers to information in your health record that could identify you.

• Treatment, Payment, and Health Care Operations

o Treatment is when a RCC therapist provides, coordinates, or manages your health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another mental health provider;

o Payment is when RCC obtains reimbursement for your healthcare. Examples of payment are when RCC or biller discloses your PHI to your health insurer to obtain reimbursement for your health care to determine eligibility or coverage.

o Health Care Operations are activities that relate to the performance and operations of RCC’s practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination

• Use applies only to activities within RCC’s office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• Disclosure applies to activities outside of RCC’s office, such as releasing, transferring, or providing access to information about you to other parties.

• Authorization is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization

RCC may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when RCC or your therapist is asked for information for purposes outside of treatment, payment, or health care operations, your therapist or RCC will obtain an authorization from you before releasing this information.
You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) RCC has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) RCC has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures without Authorization

RCC or your therapist may use or disclose PHI without your consent or authorization in the following circumstances:

• Child Abuse – If your therapist has reasonable cause to believe a child known to your therapist in a professional capacity may be an abused or neglected child, your therapist must report this belief to the appropriate authorities.

• Adult and Domestic Abuse – If your therapist has reason to believe that an individual (who is protected by state law) has been abused, neglected, or financially exploited, your therapist must report this belief to the appropriate authorities.

• Health Oversight Activities – your therapist or RCC may disclose protected health information regarding you to a health oversight agency for oversight activities authorized by law, including licensure or disciplinary actions.

• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information by any party about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state law, and RCC must not release such information without a court order. The privilege does not apply when you are being evaluated for a third party where the evaluation is court-ordered. You must be informed in advance if this is the case.

• Serious Threat to Health or Safety – If you communicate to your therapist a specific threat of imminent harm against another individual or if your therapist believes that there is a clear, imminent risk of physical or mental injury being inflicted against another individual, your therapist may make disclosures that they believe is necessary to protect that individual from harm.

• Worker’s Compensation –your therapist may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Client’s Rights and RCC Therapist Duties

Client’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information.

• Right to restrict certain disclosures of PHI to health plans/insurance companies – If you wish to restrict disclosures to your health plan/insurance company, you must pay out of pocket in full for the health care service.

• 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 a therapist. At your request, RCC 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 including mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, RCC will discuss with you the details of the request for the access process.

• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in record. RCC may deny your request. On your request, RCC 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. On your request, RCC 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 RCC upon request, even if you have agreed to receive the notice electronically.

• Right to be notified following a breach of unsecured protected health information – In the event there is a breach of unsecured protected health information, RCC will inform you of this.

RCC Therapist Duties:

• RCC and staff are required by law to maintain the privacy of PHI and to provide you with a notice of RCC’s legal duties and privacy practices with respect to PHI.

• RCC reserves the right to change the privacy policies and practices described in this notice. Unless RCC posts and distributes a notice of such changes; however,

• RCC is required to abide by the terms currently in effect.

• If RCC revises policies and procedures, RCC will post the revisions and distribute the revisions to all clients who visit RCC’s office.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision RCC makes about access to your records, or have other concerns about your privacy rights, you may contact Dr. Samantha Lussier, Psy.D. at 312-548-9051.

If you believe that your privacy rights have been violated and wish to file a complaint, you may send your written complaint to Dr. Samantha Lussier, Psy.D.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

You have specific rights under the Privacy Rule. RCC will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy

This notice is effective on June 17, 2019.

RCC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that RCC maintains. RCC will provide you with a revised notice by posting the revisions and distributing the revisions to all clients who visit RCC’s office.

Client Policies and Procedures

Fees

Standard Fees: The fee for a 45-52 minute therapy session is $200. The fee for a 53-60 minute session is $225. The initial appointment will be 53-89 minutes at a rate of $225.

Insurance: RCC may attempt to bill the client’s insurance company or the client will pay the full fee at the time of service and RCC will give the client a Super Bill for the client to obtain reimbursement from their insurance company. It will be the client’s responsibility to contact their insurance company to determine their insurance benefits, estimated out-of-pocket expense and whether preauthorization is required. If preauthorization is required, RCC or biller will work with the client to complete and submit any necessary paperwork to their insurance carrier. Payment of RCC’s standard fee is required until RCC has obtained verification of your insurance benefits. Payment of the standard fee is required until RCC has verified the client’s insurance benefits. 

Fee Payment

Payment for the portion of the fee for which you are responsible is expected at the time of service.

Please note that verification of benefits is not a guarantee of payment by the insurance company. A copy of your credit card will be placed on file and billed in the event that your insurance company does not pay for services rendered or if there is any unpaid balance. Upon notice of insurance denial, RCC or biller will make a good faith effort to contact you with information regarding your account and to establish mutually agreeable payment plans. If you have not responded after 30 days of insurance denial, your signature below acknowledges and authorizes RCC or biller to charge the full amount to your credit card.

In the event that your contact information has changed, it is important that you provide this updated information. If RCC is unable to contact you or you have not contacted RCC within 30 days after insurance denial, your signature below acknowledges and authorizes RCC or biller to charge the full amount to your credit card on file.

Confidentiality

Confidentiality is a critical part of your therapy process. RCC will respect and guard your right to maintain the confidentiality of any information you communicate, excluding instances in which disclosure is required by law, whenever any life is judged to be at risk, or during supervision or consultation. In other instances, RCC will not disclose your protected health information, including billing, without your prior written authorization. In the event of using a third-party payer, a waiver must be signed. By signing this waiver, you are responsible to let the third-party know that RCC can share billing information with them. RCC cannot accept third-party checks or credit card payments until there has been a third-party payer release form signed by the client. Please contact RCC for or refer to the privacy notice for further details.

Confidentiality of children’s records and information – According to Illinois law, parents have the right to have access to the records of their children under the age of 12. Often parents want to obtain records as they believe that this will be helpful to their children. RCC recommends against this as children frequently view this as a betrayal of the trust between child and therapist, potentially leading to distrust of adults and a reluctance to use and benefit from counseling. Instead, RCC recommends that parents/guardians participate in sessions as clinically indicated and ask the child and RCC questions to obtain themes of sessions, progress reports, or parenting advice geared to the needs of their child.

Many times, parents request access to information, often on the advice of their attorneys, for use in mediation or court proceedings regarding custody or visitation. RCC believes that children whose parents are having marital stresses, are separated, or are divorced, have even a greater need to talk to an unbiased person about their concerns regarding their family. Children need to be able to talk without fear of their statements being reported to the parents and/or used in court. Use of a child’s statements, which have been made in confidence, in a court proceeding is a significant betrayal that is potentially damaging to the child, and RCC requests that you refrain from such requests in the best interest of your child.

Updated Contact Information

In the event that any contact information changes, please notify RCC of changes to ensure timely communication.

Supervision and Consultation

To continually develop as mental health professionals, your therapist will regularly participate in the consultation and professional development. Your therapist may at times seek professional consultation from other mental health professionals regarding client issues. All discussions are confidential and de-identified. Communications are held in confidence and are for the purpose of providing the best care to clients.

Therapy Sessions

Unless otherwise agreed to, sessions are 45-55 minutes and will be billed in accordance with the appropriate billing code. If a client arrives after the agreed starting time, the session will still end at the scheduled time.

Cancellations – If you need to cancel a session, please contact your therapist 24 hours in advance. If you do not give your therapist 24-hours notice, you are responsible for a $100 no-show fee or late cancelation fee, unless you or your child are seriously ill or prohibited from coming by circumstances beyond your control. Insurance companies do not pay for missed sessions. This fee will be charged to your credit card on the date of the missed session.

Terminations – In all decisions to terminate therapy that has lasted beyond a few sessions, RCC asks you to make one additional appointment after you have stated your intention to terminate. In this final session, your decision to terminate will not be reconsidered unless you wish to do so; however, it is ideal to honor the process the client has engaged in with a proper clinical closure to services.

I have read and understood the above policies. I am consenting to participate in an assessment and or treatment with a therapist at RCC. I understand that no guarantees regarding the outcome of therapy can be given. RCC will use and share its knowledge and skills in good faith. Periodically during treatment, my therapist will evaluate progress and may change treatment goals as needed. If it becomes clear that there is a need to transition care to another therapist for any reason (e.g., the nature of symptoms being addressed, misfit of personality, lack of progress etc.,) I agree to discuss these concerns with my therapist and to participate in planning for transition to a new therapist if the issues cannot be resolved. In working toward my counseling goals with my therapist, I agree to abide by these policies. I have also received a copy of the “Notice of Policies and Practices to Protect the Privacy of Your Health Information” document in this packet.

In the event that I cancel an appointment within 24-hours or fail to attend a scheduled appointment, I hereby authorize RCC to charge to my credit card the amount of the cancellation or missed appointment fee of $100, and in the event that there is any unpaid balance, the amount of the unpaid balance.

Parents

Your Children:

Please list any medicine(s) you are currently taking, or have taken during the last 6 months. Please state all prescribed and over the counter medications.