PHOENIX RISING PSYCHOTHERAPY CENTER
Disclosure of services Form
Welcome to PHOENIX RISING PSYCHOTHERAPY CENTER. This document (the Agreement) contains important information about our 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 client/contractor rights regarding the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we 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 we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures at any 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 us unless we have taken action in reliance on it; if there are obligations imposed on us 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.
PROGRAM EXPECTATIONS: All participants are voluntary, therefore, willingness to participate in group activities and educational instruction is required. PHOENIX RISING PSYCHOTHERAPY CENTER reserves the right to end a participant’s stay in the Program. There is no cost for PHOENIX RISING PSYCHOTHERAPY CENTER Program services, however we may bill Medicaid for some services rendered to some clients/contractors. We will provide a structured program that will incorporate vocational education, as well as, groups, individual therapy, and community service opportunities. All participants will be supervised during their time in the Program. Medications of any kind are not allowed on the premises. If a participant must take a prescribed medication, the parent/legal guardian must make prior arrangements to come to the Program at a specified time and administer the medication to their child. The Program will begin as close to the time stated as possible; therefore, your promptness is greatly appreciated. Parents/guardians are expected to pick up participants no later than 6:30p.m. Please inform PHOENIX RISING PSYCHOTHERAPY CENTER Program staff of any special arrangements needed.
CONTACTING YOUR THERAPIST Due to our varied work schedules and the improbability of your therapist answering the phone when with a client/contractor, your therapist is often not immediately available by telephone. When a therapist is unavailable, the telephone is answered either by our secretaries who know where to reach the therapist, or by voice mail that is monitored frequently. Our staff are in the office Monday through Friday from 8am to 6pm to answer the phones. Your therapist will make every effort to return your call on the same day you make it, except for weekends and holidays. If you are difficult to reach, please inform us of sometimes when you will be available. If you are unable to reach your therapist and feel that you can't wait for the return call, contact your family physician or the nearest emergency room and ask for the mental health staff or psychiatrist on call. If you are experiencing a life-threatening emergency, call 911. If your therapist will be unavailable for an extended time, we 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 client/contractor and a psychologist. In most situations, we 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:
• We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of the client/contractor. These professionals are also legally bound to keep the information confidential. If you don't object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your Clinical Record (which is called "PHI" in my Notice of PHOENIX RISING PSYCHOTHERAPY CENTER Policies and Practices to Protect the Privacy of Your Health Information).
• We also have a privacy contract with our program partners. As required by HIPAA, we have a formal business associate contract with them, in which they promise to maintain the confidentiality of data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with a blank copy of this contract.
• If a client/contractor seriously threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. Florida law provides that a professional may disclose confidential information only to medical or law enforcement personnel if the professional determines that there is a probability of imminent physical injury by the client/contractor to the client/contractor or others, or there is a probability of immediate mental or emotional injury to the client/contractor.
There are some situations where we are 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 your diagnosis and treatment, such information is protected by the psychologist-client/contractor privilege law. We cannot provide any information without your (or your legal representative's) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
• If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
• If a client/contractor file a complaint or lawsuit against us, we may disclose relevant information regarding that client/contractor in order to defend ourselves.
• If a client/contractor files a worker's compensation claim, we must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought. There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a client/contractor's treatment. These situations, however, are unusual.
• If we have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that your therapist makes a report to the appropriate governmental agency, usually the Department of Children and Families. Once such report is filed, we may be required to provide additional information.
• If we determine that there is a probability that the client/contractor will inflict imminent physical injury on another, or that the client/contractor will inflict imminent physical, mental or emotional harm upon him/herself, or others, we may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the client/contractor. If such a situation arises, we will make every effort to fully discuss it with you before taking any action, and we will limit 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 we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, we keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. You should be aware that pursuant to Florida law, some test/assessment data are not part of a client/contractor's record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence or have them forwarded to another mental health professional so you can discuss the contents. If we refuse your request for access to your Clinical Record, you have a right of review, which we will discuss with you upon your request. In addition, we also keep a set of Psychotherapy Notes. These Notes are for your therapist’s own use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, your therapist’s analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to your therapist that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless your therapist determines that release would be harmful to your physical, mental or emotional health.
CLIENT/CONTRACTOR RIGHTS HIPAA provides you with several new or expanded rights about your Clinical Record and disclosures of protected health information.
These rights include requesting that your therapist amend your record; requesting restrictions on what information from your Clinical Record 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 our policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and our privacy policies and procedures.
MINORS AND PARENTS Client/contractors 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. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child's records. For children between 16 and18, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from the client/contractor and his/her parents that the parents’ consent to give up their access to their child's records. If they agree, during treatment, the therapist will provide them only with general information about the progress of the child's treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's Authorization, unless the therapist feels that the child is in danger or is a danger to someone else, in which case, the therapist will notify the parents of the concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and we will do our best to handle any objections he/she may have.
WELCOME TO PHOENIX RISING PSYCHOTHERAPY CENTER INC, WE LOOK FORWARD TO WORKING WITH YOU!!