This notice describes how protected health information about you (the client) may be shared and how you can obtain access. Protected health information (PHI) is information created or received by a health care provider, insurance provider, employer, or other health care practices.
Protected health information can contain identifiable information of an individual and can include demographic and medical information that concerns the past, present, or future physical or mental health of an individual.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other identifiable health information of an individual used or disclosed in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the client, rights to understand and control how your health information is handled. There are penalties under HIPPA for the misuse of personal health information of individual clients.
Please review carefully.
1) Your mental health records are used to provide treatment, bill, and receive payments, and conduct licensed clinical social work operations. Examples of these activities include, but not limited to, review of treatment records to ensure appropriate care, electronic or mail delivery of billing for treatment to you or other authorized payers, appointment reminder telephone calls, text messaging, or email and records review to ensure completeness and quality of care. Use and disclosure of mental health records is limited to the internal use outlined above except required by law or authorized by the patient or legal representative.
2) Federal and State laws require abuse, neglect, domestic violence, and threats to be reported to necessary authorities. If such reports are made, they will be disclosed to you or your legal representative unless disclosure increases risk of further harm.
3) Disclosed information will be limited to the minimum necessary. You may request an account ()for any uses or disclosures other than those described above.
4) You, or your legal representative, may request your records to be disclosed to yourself or any other entity. Your request must be made in writing, clearly identify the person authorized to request the release, specify the information you want disclosed, the name and address of the entity you want the information released to, purpose and the expiration date of the authorization. Any authorization provided may be revoked in writing at any time. Psychotherapy notes are part of your mental health records. Alderson Family Connections, PC has 14 days to respond to a disclosure request.
5) You may request corrections to your records.
6) A request for disclosure may be denied under the following circumstances: disclosure would likely endanger the life or physical safety of you or another person, requested information references other persons, except another healthcare provider, or if released to a legal representative would likely result in harm.
7) If a request for disclosure is denied for reasons outlined in the above statement 6, you or your legal representative may request review of the denial. A review will be conducted by another licensed healthcare provider appointed by the original reviewer, who was not involved in the original decision to deny access. A review will be concluded within 30 days.
8) You may request that we restrict uses and disclosures outlined in statement 1. However, we are not required to agree to the restrictions. If an agreement is made to restrict use or disclosure, we will be bound by such restriction until revoked by you or your legal representative in writing except when disclosure is required by law or in an emergency. We may also revoke such restrictions regarding information gathered as required by law or in an emergency. We may also revoke such restrictions, but information gathered while the restriction was in place will remain restricted by such an agreement.
9) If you wish to complain about privacy related issues you may contact the Secretary of the Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington DC, 20201. In any case there will not be any retaliation against you or your legal representative for filing a complaint.
10) This agreement may be modified or amended as required by law or in the course of health care operations.
Alderson Family Connections, PC Confidentiality Statement
Federal and state laws require any information about your intake, assessment, diagnosis, and treatment may not be released without your informed consent while you are a client of Alderson Family Connections PC or after you have been discharged from services.
HOWEVER, your protected health information can and will be released to the appropriate authorities without your consent as follows:
1) If you are a danger to yourself;
2) If you are a danger to others (violent or threatening towards others or their property);
3) If you are emotionally disable (unable to care for self-causing your life or health to be at risk);
4) If there is suspected physical, sexual, emotional, or verbal abuse or neglect of an individual under the age of 18;
5) If there is suspected abuse, neglect, or exploitation of an individual who is 65 years of age or older;
6) If we receive a subpoena accompanied by a court order:
a. to release information from your treatment records
b. regarding your arrest
c. requiring testimony in court.
Alderson Family Connections, PC is mandated by law to release information to and notify the proper authorities or persons in the above situations.
1. Client understand that if client fail to give at least 24-HOUR notice prior to cancelling or rescheduling your appointment, you will be charged a Cancellation fee in the amount of the full session.
2. Client understand that I will be charged a NO-SHOW FEE totaling the full amount of the session missed if I fail to show for my appointment. Client understand that if client is late to the appointment, client will only have the allotted time available for session. Client further understand, client is responsible for paying the full amount due for the session.
3. Client understand that client is responsible for knowing the co-payment amount once discussed and the deductible amount if insured.
4. Client understand that client will be charged a $10 late fee if client fail to make payment at the time of the appointment.
5. Client understand that these charges are an out of pocket expense and that the insurance provider does not cover these charges.
6. Client understand that the therapy session will last between 60 minutes.
CONTACTING YOUR PROVIDER
You may leave a confidential voicemail for your therapist 24 hours a day, 7 days a week. Telephone calls will be returned between 8:30 am and 4:30 pm Tuesday, Wednesday, Thursday, and Friday, unless otherwise arranged.
Email and text messaging may be used for confirmation of appointments and to communicate changes that may impact scheduled appointments.
Email or text messaging will NOT be used as a means of counseling or therapeutic exchange. In the case of a life-threatening emergency, please call 911. Our office is not a crisis center and, therefore, is not staffed 24 hours.
Alderson Family Connections, PC office hours are by appointment only. Please call and leave a message with your therapist should you need to talk outside of your regularly scheduled appointment time.
If you are a minor, your parents or legal guardian may be legally entitled to some information about your therapy. This will be discussed with you and your parents/legal guardian what information is appropriate for them to receive and which issues are more appropriately kept confidential.
The use of telehealth technology by Illinois and Indiana licensed healthcare practitioners for the purpose of providing patient care within the states of Illinois and Indiana is not precluded by Illinois and Indiana law. Telehealth technologies may be employed for patient care as long as such technologies are used in a manner that is consistent with the standard of care.
Licensed clinical social workers of Alderson Family Connections, PC can only offer online therapy service to residents in the states of Illinois and Indiana.
Telehealth will be provided through HIPAA compliant video conferencing software after an initial in person assessment regarding if online therapy is appropriate for each client.
INSURED CLIENT RESPONSIBILITY
It is the client’s responsibility to notify Alderson Family Connections PC with any insurance changes and to obtain any required authorizations. Alderson Family Connections will submit claims to the insurance company on file. Per contractual agreement with insurance companies, Alderson Family Connections must collect all co-payment and/or deductibles due. Co-payment and/or deductibles are due at the time of the appointment. If the insurance company does not cover the cost of service provided, the balance will become your responsibility.
PAYMENT OF SERVICES
It is the client’s responsibility to make payments for all services provided at time of appointment via credit card through PayPal/Venmo system. Payments made through the system are secure and will be completed at the time the client’s chart is reviewed for billing. Client making payments through Simple Practice adheres to the policies of the Stripe payment system.
All payments not made within 30 days of service and/or when invoice was sent will be seen as “refusal to pay” and subject to being sent to a collection service. Written correspondence will be sent to client two weeks before payment is sent to a collection service to provide an opportunity to arrange a payment plan with Alderson Family Connections, PC. Payment plan will be on a case by case basis and determined by client and provider. Payment plans will be noted in client’s chart as an administrative note.
RELEASE OF MENTAL HEALTH RECORDS
All clients or parents/legal guardians must complete and sign a release of information authorizing Alderson Family Connections, PC to provide any information to another. Record request may take up to 15 business days to complete.
The termination process can be difficult and should not be done abruptly to achieve the right closure. The termination process depends on the length and intensity of the treatment. Alderson Family Connections may terminate treatment after appropriate discussion with client. A termination process will occur, if it is determined that therapy is not being effectively used or if you are in default on payment. The therapeutic relationship will not be terminated without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified therapists. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, Alderson Family Connections, PC will consider the professional relationship discontinued.
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