cpancf service agreement form - Clinical Psychology Associates of ...

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If such situations arise, if prudence and safety allows, we will make a reasonable effort to fully discuss it with youbefore taking any action and we will limit my disclosure to what is necessary. While this written summary ofexceptions to confidentiality should prove helpful in informing you about potential problems, it is important that wediscuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can bequite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may beneeded.PROFESSIONAL RECORDSThe laws and standards of my profession require that we keep Protected Health Information about you in yourClinical Record. Except in unusual circumstances that disclosure would physically endanger you and/or others ormakes reference to another person (other than a health care provider) and we believe that access is reasonably likelyto cause substantial harm to such other person, you may examine and/or receive a copy of your Clinical Record, ifyou request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting tountrained readers. For this reason, we recommend that you initially review them in our presence, or have themforwarded to another mental health professional so you can discuss the contents.In most circumstances, we are allowed to charge a copying fee of $1.00 per page for the first 25 pages and 25 centsper page thereafter as well as postage or other costs associated with furnishing you these records. We may withholdcopies of your records until payment of the copying fees has been made. If we refuse your request for access to yourrecords, you have a right of review, which we will discuss with you upon request. You agree that unless a medicalemergency exists, provision of records within 30 days of request will be considered timely.PATIENT RIGHTSWith certain exceptions, such as those involved in forensic, legal or Worker’s Compensation matters, HIPPAprovides rights with regard to your clinical records and disclosures of protected health information. These rightsinclude requesting that we amend your record; requesting restrictions on what information from your ClinicalRecords is disclosed to others; requesting an accounting of most disclosures of protected health information that youhave neither consented to nor authorized; determining the location to which protected information disclosures aresent; having any complaints you make about our policies and procedures recorded in your records; and the right to apaper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. We are happy todiscuss any of these rights with you.MINORS & PARENTSPatients under 18 years of age who are not emancipated and their parents should be aware that the law may allowparents to examine their child’s treatment records. Children between 13 and 17 may independently consent to (andcontrol access to the records of) diagnosis and treatment in a crisis situation. Because privacy in psychotherapy isoften crucial to successful progress, particularly with teenagers, and parental involvement, is also essential, we mayrequest an agreement with minors [over 12] and their parents about access to information. This agreement providesthat during treatment, we will provide parents only with general information about the progress of the treatment, andthe patient’s attendance at scheduled sessions. We may also provide parents with a summary of their child’streatment when it is complete. In these cases, we may require the child’s Authorization, unless we feel that the childis in danger or is a danger to someone else, in which case, we will notify the parents of our concerns. Before givingparents any information, we will discuss the matter with the child, if possible, and do our best to handle anyobjections he/she may have.It is our understanding that Federal laws are more stringent in protecting release of Drug and Alcohol informationregarding adults as well as minor children. While we recognize the serious parental concerns in this regard, wecannot release such information without your child’s informed consent.6
By presenting your minor child for treatment, you are representing and affirming that you have legal parentalauthority to do so. Unless parental rights have been terminated, or there have been other specific restrictionsimposed by the court or law, you are affirming that both parents have equal rights to information about diagnosisand treatment under the law.COMPLAINTS ABOUT SERVICESWe strive to provide quality services in a caring and professional manner. However, we understand that sometimesdisagreements or complaints regarding services can occur. We encourage you to first discuss these directly with theindividual involved in order to directly solve any problem. If you wish, or if this does not provide adequate remedy,you may contact our Executive Director, Ernest J. Bordini, Ph.D.BILLING AND PAYMENTSYou will be expected to pay for each session at the time it is held, unless we agree otherwise or unless you haveinsurance coverage that requires another arrangement. Payment schedules for other professional services will beagreed to when they are requested.A service fee of $25.00 per month shall apply to any accounts which there is an outstanding balance and paymentsare late, delinquent, or which there has been no payment made by you or your insurance company on the balancewithin the past 30 days.A minimum charge of 15 minutes of time will be charged for completion of any forms for your employer or otherentity. This may be charged at $130.00 per hour to $250.00 per hour in 15 minute increments depending on thenature and complexity of the form and normally will not be billed to insurance.Patient statements are usually sent the last week of each month. The portion marked patient responsibility is dueupon receipt. We accept Visa and MasterCard. You may arrange to bill copayments and deductibles automaticallyby contacting our office manager. Other payment arrangements must be made in advance.If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon,we have the option of using legal means to secure the payment. This may involve hiring a collection agency or goingthrough court which will require us to disclose otherwise confidential information. In most collection situations, theonly information we release regarding a patient’s treatment is his/her name, personal identifying information,payment history, information about any agreements or authorizations made regarding payment or responsibility forservices, the nature of services provided, and the amount due. If such legal action is necessary, its costs will beincluded by us or our attorney in the claim.By signing this agreement you understand that you are responsible for reasonable attorney and legal fees foraccounts that go to collections. We will also release information necessary to file a adverse credit report withEquifax or other such agency.Our Office Managers are Ms. Jackie Williams and Ms Darlene Wise. They are generally available to answer billingand insurance questions between 9:00 a.m. and 4:00 p.m. Monday to Friday.SPECIAL ACCOMMODATIONSIf you require any special accommodations for purposes of evaluation or treatment, you agree that you will provide awritten statement of what you require such that it may be discussed at your first visit. We will make reasonable7
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