A mental health professional (as defined by this statute) may provide psychotherapy services (as defined) to a minor 12 or older, if the mental health professional determines that: (1) the minor is knowingly and voluntarily seeking such services, and (2) the provision of psychotherapy services is clinically indicated and necessary to the minor’s well-being. Colo. Rev. Stat. §. 12-245-203.5.

Troy Schmiek is only licensed in the state of Colorado. A client who is physically in the state of Colorado can be seen by Troy Schmiek. If the client is NOT going to be in Colorado during the time of sessions please notify the provider via phone call or text message (720-458-6543).

You as the client are ultimately responsible for the payment for treatment and care rendered by Troy Schimek at Mainstreet Pediatrics. It is your responsibility to provide updated and correct insurance information. You are responsible for payment of copays, coinsurance, deductibles, and all other procedures or treatment not covered by your insurance plan. Copays are due at the time of service unless other arrangements have been made. You may incur, and are responsible for payments of additional charges.

- Sessions are scheduled for 50 minutes, however the assessment can be up to 80
minutes and will be charged accordingly.
- You are responsible for full payment of all services. If your insurance refuses a claim or does not pay the full service fee, you will be required to pay the entire amount.
- Any fees unpaid for 120 days are subject to collections. In collection situations,
Mainstreet Pediatrics will make all efforts to release the minimum information necessary to proceed with collections or a claim, which will include the client name, dates, times, and the nature of services, and the amount due. Before Higher Sights engages a collection agency, we will provide you with written notice of my intent to do so, sent to your last address we have on record, and give you an opportunity to make payment arrangements.

- Services for Medicaid members will not be charged as Medicaid covers the entire service fee (unless you have a CHP+ plan), however, if your insurance does not pay for a service due to a denial or lapse in insurance, you are financially responsible for that service, so a credit card required.
- Mainstreet does not bill for EAP benefits, only general benefits of insurance
plans.
-If Troy Schimek and/or administrator has to participate in court for any reason the fee to the client (or guardian if the client is a minor) is $300 per hour (with a 4-hour minimum) which includes time to do paperwork, drive time from the moment they leave their house for court, the hours in court, and any additional court-related hours for a case. This applies to each individual involved (i.e. the therapist's time is $300 per hour for a minimum of 4 hours, and if an administrator is involved the fee for them will also be an additional $300 per hour for a minimum of 4 hours).

Higher Sights Counseling LLC provides marketing services, office space,
credentialing, billing support, and administrative services to our providers.
Independent-contract clinicians do not supervise or receive supervision from Higher
Sights. Independent Contractors at Higher Sights are not in a partnership, and have no responsibility for each othersʼ practices. Independent contractors are responsible and liable for the care they provide to their clients/patients.

1. Understand your rights.
2. Follow the Health First Coloradoʼs (Coloradoʼs Medicaid Program) handbook.
3. Treat other members, your providers and staff with respect.
4. Choose a provider from your plan network or call us if you want to see a different provider.
5. Pay for services you get that are not covered by Health First Colorado.
6. Tell your provider and Health First Colorado if you have other insurance or family
or address changes.
7. Ask questions when you do not understand or want to learn more.
8. Tell your provider information they need to care for you, such as your symptoms.
9. Take medications as prescribed and tell your provider about side effects or if your medications are not helping.
10. Invite people who will be helpful and supportive to you to be included in your
treatment.
11. Report suspected member or provider fraud or abuse to Member Fraud at 844-
475-0444 or Provider Fraud at 855-375-2500.
12. Learn about your health benefits and how to use them.
13. Following your treatment plan.
14. Tell your PCMP, provider, or care coordinator if you do not understand your
treatment plan.
15. Go to your appointments on time or call your provider if you will be late or cannot keep your appointment.

Please note that your therapist will be sending you a treatment plan listing the goals you two agreed upon together for treatment. It is required for us to have a signed copy on file so you will be sent a treatment plan to eSign following your first session.
*PLEASE NOTE if the treatment plan (and also the assessment if you are a Medicaid
client) are not signed within 30 days services will be paused until signed.

Your therapist or Higher Sights staff may use or disclose PHI without your consent or authorization in certain circumstances, including, but not limited to:
• Child or At-Risk Adult Abuse: If they have reasonable cause to know or suspect that a child has been subjected to abuse or neglect or an at-risk adult has been mistreated, self-neglected, or financially exploited or is at imminent risk of mistreatment, self-neglect, or financial exploitation, then they must report this to the appropriate authorities.
• Health Oversight Activities: If the Colorado state licensing board or an authorized professional review committee is reviewing my services, they may disclose PHI to that board or committee.
• Judicial and Administrative Proceedings: If you are involved in a court proceeding where you are being evaluated for a third party or where the evaluation is court ordered, they may disclose PHI to the court. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety: If you communicate to your therapist or a Higher Sights staff member a serious threat of imminent physical violence against a specific person or persons, including those identifiable by association with a specific place, they have a duty to notify any person or persons specifically threatened, as well as a duty to protect by taking other appropriate action. If they believe that you are at imminent risk of inflicting serious harm on yourself, they may disclose information necessary to protect you. In either case, they may disclose information in order to initiate hospitalization.
• Business Associates: Higher Sights may enter into contracts with business associates that are outside entities to provide billing, legal, auditing, and practice management services. In those situations, protected health information will be provided to those contractors as needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
• In Compliance with Other State/Federal Laws and Regulations: PHI may be disclosed when the use and disclosure is allowed under other sections of Section 164.512 of the Privacy Rule and the stateʼs confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS), to a medical examiner, for public health purposes relating to
disease or FDA-regulated products, or for specialized government functions (fitness for military duties, eligibility for VA benefits, etc.)

When it comes to your PHI, you have certain rights. This section explains your rights and some of Higher Sightsʼs responsibilities to help you.
• Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information regarding you. The request must be in writing, and 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
your therapist. On your request, your therapist/Higher Sights staff 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. Your therapist of Higher Sights staff may deny your access to PHI under certain circumstances,
but in some cases you may have this decision reviewed. On your request, your therapist 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. Your therapist may deny your request. On your request, your therapist 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, your therapist 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.
• Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

As a mental health provider, your therapist and Higher Sights staff have certain duties to you related to your PHI. These are described below.
• Your therapist and Higher Sights staff is 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.
• Your therapist and Higher Sights staff is required to notify you if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.
• Your therapist and Higher Sights staff is reserve the right to change the privacy policies and practices described in this notice. Unless they notify you of such changes, however, they are required to abide by the terms currently in effect.
• If your therapist and/or Higher Sights staff is revise my policies and procedures, they will send a revised Notice of Privacy Practices by mail or email to the address that is in your record.

If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact the Privacy Officer, Caitlyn Wright, at 720-943-7080.
If you believe that your privacy rights have been violated and wish to file a complaint with my office, you may send your written complaint to Caitlyn Wright via email to Caitlyn@HigherSightsCounseling.com.
You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. Centralized Case Management Operations, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F HHH Bldg., Washington, D.C. 20201, or email to OCRComplaint@hhs.gov (mailto:OCRComplaint@hhs.gov). Higher Sights Counseling will not retaliate against you for exercising your right to file a complaint.
This Notice is effective March 2022.

1. After your intake assessment, your assigned therapist will hold a weekly time slot reserved just for you. To make the most of your therapy, it is to your benefit for you to commit to attending all scheduled sessions. We understand that occasional emergencies arise beyond your control, at which time it is important that you contact Mainstreet Pediatrics to reschedule or cancel your appointment. We require that any changes or cancellations be made at least 24 hours in advance (but we prefer as much notice as possible).

2. After 2 missed appointments without 24-hour notice, the therapist may remove you from his/her regular schedule and place you on a waiting list. Clients can request an appointment on their provider’s schedule which may be approved 24 hours before the opening if the provider has availability. After attending 2 consecutive sessions from the waitlist, you may be placed on a regular-scheduled time if the provider has availability.

3. If you cancel (even with 24 hours notice) 3 scheduled sessions within a 2-month period, you may be placed on a waitlist and offered appointments as they are available. After attending 2 sessions from the waitlist that you have booked, you may be placed back on a regular-scheduled time if the provider has availability.

4. Missed appointments not only impede your progress, but they prevent another client in need from receiving services. Please note that Medicaid and other insurance companies will not pay for missed sessions.

If you have any questions or concerns regarding this policy,
please feel free to discuss it with Mainstreet Pediatrics management.

Mainstreet Pediatrics requires a credit card on file for private-pay and private insurance clients seeing Troy Schimek, LPC.

I acknowledge that Mainstreet Pediatrics will keep my credit card information confidential, and that any changed, canceled, or missed appointment with less than 24-hour notice will result in a charge of $100.00.

1. After your intake assessment, your assigned therapist will hold a weekly time slot reserved just for you. To make the most of your therapy, it is to your benefit for you to commit to attending all scheduled sessions. We understand that occasional emergencies arise beyond your control, at which time it is important that you contact Mainstreet Pediatrics to reschedule or cancel your appointment. We require that any changes or cancellations be made at least 24 hours in advance (but we prefer as much notice as possible).

2. After 2 missed appointments without 24-hour notice, the therapist may remove you from his/her regular schedule and place you on a waiting list. Clients can request an appointment on their provider’s schedule which may be approved 24 hours before the opening if the provider has availability. After attending 2 consecutive sessions from the waitlist, you may be placed on a regular-scheduled time if the provider has availability.

3. If you cancel (even with 24 hours notice) 3 scheduled sessions within a 2-month period, you may be placed on a waitlist and offered appointments as they are available. After attending 2 sessions from the waitlist that you have booked, you may be placed back on a regular-scheduled time if the provider has availability.

4. Missed appointments not only impede your progress, but they prevent another client in need from receiving services. Please note that Medicaid and other insurance companies will not pay for missed sessions.

If you have any questions or concerns regarding this policy,
please feel free to discuss it with Mainstreet Pediatrics management.