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Privacy Statement

1. HIPAA NOTICE OF PRIVACY PRACTICES
2. AUTHORIZATION TO RELEASE INFORMATION
3. REQUEST FOR AMENDMENT OF HEALTH INFORMATION
4. OFFICE POLICIES & GENERAL INFORMATION AGREEMENT FOR PSYCHOTHERAPY SERVICES
5. CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT, PAYMENT, AND HEALTH
     CARE  OPERATIONS (TPO)

 

HIPAA NOTICE OF PRIVACY PRACTICES

I. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

II. IT IS OUR LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law we are required to insure that your PHI is kept private. The PHI constitutes information created or noted by Tri-Cities Psychological Services, Inc. that can be used to identify you. It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care. We are required to provide you with this Notice about our privacy procedures. This Notice must explain when, why, and how we would use and/or disclose your PHI. Use of PHI means when we share, apply, utilize, examine, or analyze information within our practice; PHI is disclosed when we release, transfer, give, or otherwise reveal it to a third party outside our practice. With some exceptions, we may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, we are always legally required to follow the privacy practices described in this Notice.

Please note that we reserve the right to change the terms of this Notice and my privacy policies at any time. Any changes will apply to PHI already on file with us. Before we make any important changes to our policies, we will immediately change this Notice and post a new copy of it in our office and on our website. You may also request a copy of this Notice from us, or you can view a copy of it in our office or on our website, which is located at www.TCPsych.com.

III. HOW WE WILL USE AND DISCLOSE YOUR PHI.
Tri-Cities Psychological Services, Inc. will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of our uses and disclosures, with some examples.
A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent. We may use and disclose your PHI without your consent for the following reasons:
1. For treatment. We may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, we may disclose your PHI to her/him in order to coordinate your care.

2. For health care operations. We may disclose your PHI to facilitate the efficient and correct operation of our practice. Examples: Quality control - We might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. We may also provide your PHI to our attorneys, accountants, consultants, and others to make sure that we are in compliance with applicable laws.

3. To obtain payment for treatment. We may use and disclose your PHI to bill and collect payment for the treatment and services we provided you. Example: We might send your PHI to your insurance company or health plan in order to get payment for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for our office.

4. Other disclosures. Examples: Your consent isn't required if you need emergency treatment provided that we attempt to get your consent after treatment is rendered. In the event that we try to get your consent but you are unable to communicate with us (for example, if you are unconscious or in severe pain) but we think that you would consent to such treatment if you could, we may disclose your PHI.

B Certain Other Uses and Disclosures Do Not Require Your Consent. We may use and/or disclose your PHI without your consent or authorization for the following reasons:
 

1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or, law enforcement. Example: We may make a disclosure to the appropriate officials when a law requires us to report information to government agencies, law enforcement personnel and/or in an administrative proceeding.

2. If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.

3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.

4. If disclosure is compelled by the patient or the patient’s representative pursuant to Illinois Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.

5. To avoid harm. We may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public.

6. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.

7. If disclosure is mandated by the Illinois Child Abuse and Neglect Reporting law. For example, if we have a reasonable suspicion of child abuse or neglect.

8. If disclosure is mandated by the Illinois Elder/Dependent Adult Abuse Reporting law. For example, if we have a reasonable suspicion of elder abuse or dependent adult abuse.

9. If disclosure is compelled or permitted by the fact that you tell us of a serious/imminent threat of physical violence by you against a reasonably identifiable victim or victims.

10. For public health activities. Example: In the event of your death, if a disclosure is permitted or compelled, we may need to give the county coroner information about you.

11. For health oversight activities. Example: We may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.

12. For specific government functions. Examples: We may disclose PHI of military personnel and veterans under certain circumstances. Also, we may disclose PHI in the interests of national security, such as protecting the President of the United States or assisting with intelligence operations.

13. For research purposes. In certain circumstances, we may provide PHI in order to conduct medical research.

14. For Workers' Compensation purposes. We may provide PHI in order to comply with Workers' Compensation laws.

15. Appointment reminders and health related benefits or services. Examples: We may use PHI to provide appointment reminders. We may use PHI to give you information about alternative treatment options, or other health care services or benefits we offer.

16. If an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.

17. We are permitted to contact you, without your prior authorization, to provide appointment reminders or information about alternative or other heath-related benefits and services that may be of interest to you.

18. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law. Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess our compliance with HIPAA regulations.

19. If disclosure is otherwise specifically required by law.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object.
1. Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections IIIA, IIIB, and IIIC above, we will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that we haven't taken any action subsequent to the original authorization) of your PHI by us.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
These are your rights with respect to your PHI:
A. The Right to See and Get Copies of Your PHI. In general, you have the right to see your PHI that is in our possession, or to get copies of it; however, you must request it in writing. If we do not have your PHI, but we know who does, we will advise you how you can get it. You will receive a response from us within 30 days of our receiving your written request. Under certain circumstances, we may feel we must deny your request, but if we do, we will give you, in writing, the reasons for the denial. We will also explain your right to have my denial reviewed.

If you ask for copies of your PHI, we will charge you not more than $.25 per page. We may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

B. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask that we limit how we use and disclose your PHI. While we will consider your request, we am not legally bound to agree. If we do agree to your request, we will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that we are legally required or permitted to make.

C. The Right to Choose How we Send Your PHI to You. It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). We are obliged to agree to your request providing that we can give you the PHI, in the format you requested, without undue inconvenience.

D. The Right to Get a List of the Disclosures we Have Made. You are entitled to a list of disclosures of your PHI that we have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After April 15, 2003, disclosure records will be held for six years.

We will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list we give you will include disclosures made in the previous six years (the first six year period being 2003-2009) unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. We will provide the list to you at no cost, unless you make more than one request in the same year, in which case we will charge you a reasonable sum based on a set fee for each additional request.

E. The Right to Amend Your PHI. If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that we correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of our receipt of your request. We may deny your request, in writing, if we find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of our records, or (d) written by someone other than us. Our denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and our denial be attached to any future disclosures of your PHI. If we approve your request, we will make the change(s) to your PHI. Additionally, we will tell you that the changes have been made, and we will advise all others who need to know about the change(s) to your PHI.

F. The Right to Get This Notice by Email You have the right to get this notice by email. You have the right to request a paper copy of it, as well.

V. HOW TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If you file a complaint about our privacy practices, we will take no retaliatory action against you.

VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN ABOUT OUR PRIVACY PRACTICES
If you have any questions about this notice or any complaints about our privacy practices, or would like to know how to file a complaint with the Secretary of the Department of Health and Human Services, please contact us at: Tri-Cities Psychological Services, Inc. 65 North River Lane, Suite 204, Geneva, IL 60134, or by phone: (630) 845-9644.

VII. EFFECTIVE DATE OF THIS NOIICE
This notice went into effect on April 14, 2003.

I acknowledge receipt of this notice

Patient Name: __________________ Date: ______ Signature: _______________

Patient Name: __________________ Date: ______ Signature: _______________

Patient Name: __________________ Date: ______ Signature: _______________
 

 

 

AUTHORIZATION TO RELEASE INFORMATION

I, (name of patient) ______________________________, (hereinafter “Patient”) hereby authorize (name of psychotherapist)
__________________ , (hereinafter “Provider”) to disclose mental health treatment information and records obtained in the course of
psychotherapy treatment of Patient, including, but not limited to, therapist’s diagnosis of Patient, to:
________________________________________
_________________________________________

I understand that I have a right to receive a copy of this authorization. I understand that any cancellation or modification of this
authorization must be in writing. I understand that I have the right to revoke this authorization at any time unless Provider has taken
action in reliance upon it. And, I also understand that such revocation must be in writing and received by Provider at (insert
therapist’s address) ______________________________________________________ to be effective.

This disclosure of information and records authorized by Patient is required for the following purpose:
____________________________________________________________
The specific uses and limitations of the types of medical information to be discussed are as follows (be as specific as you choose to) :
______________________________
______________________________________________________________________________________________________
_____________________________________________________

Such disclosure shall be limited to the following specific types of information: ______________________________________________________________________________________________________
_____________________________________________________.
Therapist shall not condition treatment upon Patient signing this authorization and Patient has the right to refuse to sign this form.

Patient understands that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule, although applicable California law may protect such information.

This authorization shall remain valid until: _____________________________________

Patient’s signature: __________________________________ Date:___________________

 

 

REQUEST FOR AMENDMENT OF HEALTH INFORMATION

Date: ________
Patient name: ____________________________________________________
Birth date: ______________ Phone: __________________________________
Patient address: __________________________________________________
Describe the information you would like to have amended:
____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________

Date(s) of information to be amended (e.g., date of office visit(s):
____________________________________________________________________ ____________________________________________________________________

What is your reason for making this request? (i.e., the information is incorrect, incomplete, or outdated) ________________________________________________________
________________________________________________________

How is the information you want to amend incorrect, incomplete, or outdated? ________________________________________________________
________________________________________________________

What should the entry say (or not say) to be more accurate or complete? ______________________________________________________
_______________________________________________________

Do you know of anyone who may have received or relied on the information in question (such as your doctor, health plan, or other health care provider)? Yes/No

If yes, please specify the name(s) and address(es) of the organization(s) or individual(s).

Signature of patient or legal representative: _____________

Date: ________________
 

 

OFFICE POLICIES & GENERAL INFORMATION
AGREEMENT FOR PSYCHOTHERAPY SERVICES

 

This form provides you (patient) with information that is additional to that detailed in the Notice of
Privacy Practices.

CONFIDENTIALITY: All information disclosedwithin sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your (client’s) written permission, except where disclosure is required by law. Most of the provisions explaining when the law requires disclosure were described to you in the Notice of Privacy Practices that you received with this form.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder, abuse or neglect; and where a client presents a danger to self, to others, to property, or is gravely disabled (for more details see also Notice of Privacy Practices form).

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by Tri-Cities Psychological Services, Inc. In couple and family therapy, or when different family members are seen individually, confidentiality and privilege do not apply between the couple or among family members. Tri-Cities Psychological Services, Inc. will use clinical judgment when revealing such information. Tri-Cities Psychological Services, Inc. will not release records to any outside party unless authorized to do so by all adult family members who were part of the treatment.

Emergencies: If there is an emergency during our work together, or in the future after termination, where Tri-Cities Psychological Services, Inc. becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, we will do whatever we can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, we may also contact the person whose name you have provided on the contact sheet.

Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct Tri-Cities Psychological Services, Inc., only the minimum necessary information will be communicated to the carrier. Unless authorize by you explicitly the Psychotherapy Notes will not be disclosed to your insurance carrier. Tri-Cities Psychological Services, Inc. has no control or knowledge over what insurance companies do with the information he/she submits or who has access to this information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy, or to future eligibility to obtain health or life insurance. The risk stems from the fact that mental health information is entered into insurance companies’ computers and soon will also be reported to the, congress-approved, National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question, as computers are inherently vulnerable to break-ins and unauthorized access. Medical data has been reported to have been sold, stolen, or accessed by enforcement agencies; therefore, you are in a vulnerable position.

Confidentiality of E-mail, Cell Phone and Faxes Communication: It is very important to be aware that e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence, the privacy and confidentiality of such communication can be compromised. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Faxes can easily be sent erroneously to the wrong address. Please notify Tri-Cities Psychological Services, Inc. at the beginning of treatment if you decide to avoid or limit in any way the use of any or all of the above-mentioned communication devices. Please do not use e-mail or faxes for emergencies.

Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on Tri-Cities Psychological Services, Inc. to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested.

Consultation: Tri-Cities Psychological Services, Inc. may consult with other professionals regarding clients; however, the client’s name or other identifying information is never mentioned. The client’s identity remains completely anonymous, and confidentiality is fully maintained.

* Considering all of the above exclusions, if it is still appropriate, upon your request, Tri-Cities Psychological Services, Inc. will
release information to any agency/person you specify unless Tri-Cities Psychological Services, Inc. concludes that releasing
such information might be harmful in any way.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Tri-Cities Psychological Services, Inc. between sessions, please leave a message at (630)845-9644 and your call will be returned as soon as possible. Tri-Cities Psychological Services, Inc. checks messages a few times a day, unless out of town. If an emergency situation arises, please call 911.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $150.00 per 50 minute session at the end of each session unless other arrangements have been made. Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed otherwise. Please notify Tri-Cities Psychological Services, Inc. if any problem arises during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, Tri-Cities Psychological Services, Inc. will provide you with a copy of your receipt on a monthly basis, which you can then submit to your insurance company for reimbursement if you so choose. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems, which are the focus of psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.

MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of Tri-Cities Psychological Services, Inc. and client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed. In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Kane County, Illinois in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed. Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Tri-Cities Psychological Services, Inc. can use legal means (court, collection agency, etc.) to obtain payment. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorneys’ fees. In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY/EVALUATION: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits; however, requires effort on your part. Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. Tri-Cities Psychological Services, Inc. will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in your experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc. or experiencing anxiety, depression, insomnia, etc. Tri-Cities Psychological Services, Inc. may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that can cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Tri-Cities Psychological Services, Inc. is likely to draw on various psychological approaches according, in part, to the problem that is being treated and his/her assessment of what will best benefit you. These approaches include behavioral, cognitive-behavioral, psychodynamic, existential, system/family, developmental (adult, child, family), or psycho-educational.

Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, Tri-Cities Psychological Services, Inc. will discuss with you (client) our working understanding of the problem, treatment plan, therapeutic objectives, and our view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, Tri-Cities Psychological Services, Inc.’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits. If you could benefit from any treatment that Tri-Cities Psychological Services, Inc. does not provide, we have an ethical obligation to assist you in obtaining those treatments.

Termination: As set forth above, after the first couple of meetings, Tri-Cities Psychological Services, Inc. will assess if we can be of benefit to you. Tri-Cities Psychological Services, Inc. does not accept clients who, in our opinion, we cannot help. In such a case, we will give you a number of referrals that you can contact. If at any point during psychotherapy, Tri-Cities Psychological Services, Inc. assesses that we are not effective in helping you reach the therapeutic goals, we are obliged to discuss it with you and, if appropriate, to terminate treatment. In such a case, we would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, Tri-Cities Psychological Services, Inc. will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, Tri-Cities Psychological Services, Inc. will assist you in finding someone qualified, and, if we have your written consent, we will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, Tri-Cities Psychological Services, Inc. will offer to provide you with names of other qualified professionals whose services you might prefer.

Dual Relationships: Not all dual relationships are unethical or avoidable. Therapy never involves sexual or any other dual relationship that impairs Tri-Cities Psychological Services, Inc.’s objectivity, clinical judgment, or therapeutic effectiveness or can be exploitative in nature. Tri-Cities Psychological Services, Inc. will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients. Geneva is a small town and many clients know each other and their psychologist from the community. Consequently you may bump into someone you know in the waiting room or into your psychologist out in the community. Tri-Cities Psychological Services, Inc. will never acknowledge working therapeutically with anyone without his/her written permission. Many clients choose Tri-Cities Psychological Services, Inc. for therapy because they know the psychologist before they enter into therapy and/or are aware of his/her stance on the topic. Nevertheless, Tri-Cities Psychological Services, Inc. will discuss with you, our client/s, the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time. It is your, the client’s, responsibility to communicate to Tri-Cities Psychological Services, Inc. if the dual relationship becomes uncomfortable for you in any way. Tri-Cities Psychological Services, Inc. will always listen carefully and respond accordingly to your feedback. Tri-Cities Psychological Services, Inc. will discontinue the dual relationship if we find it interfering with the effectiveness of the therapeutic process or the welfare of the client and, of course, you can do the same at any time.

CANCELLATION: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.

I have read the above Agreement and Office Policies and General Information carefully; I understand them and agree to comply with them:

_________________________________________________________
Client name (print) Date Signature

_________________________________________________________
Client name (print) Date Signature

_________________________________________________________

Therapist Date Signature

 

CONSENT TO USE OR DISCLOSE INFORMATION FOR TREATMENT,
PAYMENT,AND HEALTH CARE OPERATIONS (TPO)

Patient Name: ____________________________________

Federal regulations (HIPAA) allow me to use or disclose Protected Health Information (PHI) from your record in order to provide treatment to you, to obtain payment for the services we provide, and for other professional activities (known as “health care operations.”). Nevertheless, I ask your consent in order to make this permission explicit. The Notice of Privacy Practices describes these disclosures in more detail. You have the right to review the Notice of Privacy Practices before signing this consent. We reserve the right to revise our Notice of Privacy Practices at any time. If we do so, the revised Notice will be posted in the office. You may ask for a printed copy of our Notice at any time.

You may ask us to restrict the use and disclosure of certain information in your record that otherwise would be disclosed for treatment, payment, or health care operations; however, we do not have to agree to these restrictions. If we do agree to a restriction, that agreement is binding.

You may revoke this consent at any time by giving written notification. Such revocation will not affect any action taken in reliance on the consent prior to the revocation.

This consent is voluntary; you may refuse to sign it. However, we are permitted to refuse to provide health care services if this consent is not granted, or if the consent is later revoked.

I hereby consent to the use or disclosure of my Protected Health Information as specified above.

Signature of Patient: ______________________________________ Date: ___________