Servicing Alabama, Tennessee and Nevada, at MRTherapy Wellness Space LLC, we provide a friendly and understanding environment. We offer a comfortable therapeutic space with valuable resources for every client and want to make sure, at all times, that our clients feel ready to focus on their mental health needs. ...
This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
HIPAA requires that I 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 explains HIPAA and its application to your PHI in greater detail.
The law requires that I obtain your signature acknowledging that I have provided you with this. If you have any questions, it is your right and obligation to ask so I can have a further discussion prior to signing this document. 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 unless I have taken action in reliance on it.
The law protects the privacy of all communication between a patient and a therapist. In most situations, I 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 some situations where I am permitted or required to disclose information without either your consent or authorization. If such a situation arises, I will limit my disclosure to what is necessary. Reasons I may have to release your information without 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-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order me to disclose information.
• If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.
• If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
• If a patient files a worker's compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.
• I may disclose the minimum necessary health information to my business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. My business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient's treatment:
•If I know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that I file a report with the Tennessee or Las Vegas Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
If I know or have reasonable cause to suspect that a vulnerable adult has been abused, neglected, or exploited, the law requires that I file a report with the Las Vegas Abuse Hotline. Once such a report is filed, I may be required to provide additional information.
If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.
Use and Disclosure of Protected Health Information:
● For Treatment – I use and disclose your health information internally in the course of your treatment. If I wish to provide information outside of our practice for your treatment by another health care provider, I will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
● For Payment – I may use and disclose your health information to obtain payment for services provided to you as delineated in the Therapy Agreement.
● For Operations – I may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. I may also use your information to tell you about services, educational activities, and programs that I feel might be of interest to you.
● Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
● Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. I will agree to such unless a law requires us to share that information.
● Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, 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.
● Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of $.25 per page. Please make your request well in advance and allow 2 weeks to receive the copies. If I refuse your request for access to your records, you have a right of review, which I will discuss with you upon request.
● Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and I will decide if it is and if I refuse to do so, I will tell you why within 60 days.
● Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
● Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.
● Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; I will make sure the person has this authority and can act for you before I take any action.
● Right to Choose – You have the right to decide not to receive services with me. If you wish, I will provide you with names of other qualified professionals.
● Right to Terminate – You have the right to terminate therapeutic services with me at any time without any legal or financial obligations other than those already accrued. I ask that you discuss your decision with me in session before terminating or at least contact me by phone letting me know you are terminating services.
● Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not I think releasing the information in question to that person or agency might be harmful to you.
• I am 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. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will provide you with a revised notice in office during our session.
If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me, the State of Las Vegas Department of Health, or the Secretary of the U.S. Department of Health and Human Services.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.
PHONE/CHAT/VIDEO SESSIONS: When participating in video, chat or phone sessions, I understand that my credit/debit card information will be kept on file, and I authorize my therapist to charge my card at the time of the session or afterwards.
MISSED SESSIONS: I understand that when I schedule an appointment, whether in- person or by video or phone, that time is held for me. I also understand that insurance or EAP plans typically will not pay for missed sessions. Therefore, I understand my credit/debit card information will be kept on file, and if I cancel or reschedule a session without 24 hours’ notice or if I do not show for the appointment, I authorize my therapist to charge my card for the missed session. If using insurance, the missed session fee will be the full session fee (not just my insurance copayment).
HEALTH SAVINGS ACCOUNTS (HSA) CARDS: If I have an HSA credit card, I authorize my therapist to charge the card for services at the time of the service or afterwards. I understand that missed sessions cannot be billed to HSA credit cards, nor can I bill sessions in advance on HSA cards.
OTHER CHARGES: Other charges that may be billed to your credit card are bank fees for bounced checks, or any balances not paid within 30 days.
OTHER PAYMENT OPTIONS: If I prefer not to use my credit card, I understand I may pay in advance for sessions by sending a check. However, I understand that a credit card will be kept on file to cover missed sessions, bounced checks, and unpaid balances.
My fee for Therapeutic services is as follows:
** All fees have an additional $10-20 processing charge through Square or Stripe
Other Non Clinical Therapeutic Session Services:
All court fees are doubled for out of town court appearances and hotel fees are expected to be paid by the client. Bills will be presented to the client and or attorney on a weekly basis and payment will be required on the date of recite. Out of town court appearances are considered any town/city outside the range of 60 miles from my office location. There is a hotel reimbursement fee standard of no less than $170 per night.
Household or annual income below $90,000: fee is $150 ( a limited # of slots available)
Families and or individuals who qualify for this option will be given 6 sessions at this sliding scale rate. This includes intake sessions and parent consultations. Once 6 sessions are completed we can review whether you would like to continue services at the non-sliding scale rate or would like a referral at that time. Families and or individuals will be required to provide documentation demonstrating household annual income by any of the following: monthly, bi- weekly or weekly. If there are not slots available for at the time you inquire for service you can choose to be placed on my waiting list.
Engaging in mental health therapeutic services is an investment in your total well-being and is most effective and life-changing with consistency and commitment. Your therapeutic hour is held exclusively for them, and to maintain therapeutic consistency sessions can be rescheduled per this office's same-week reschedule policy. You may reschedule your session within the same 5 day business week (Sunday through Thursday). For example, if the session is on Thursday you can reschedule between Friday of the same week. A reschedule request must be made 24 hours in advance within the Sunday- Thursday time frame. Reschedule requests must be in writing by either text or email. This office is closed Saturday, so, voicemails, emails, and text messages may not be checked until the following Sunday. Thus, reschedule requests must be made between Sunday- Thursday. For example, a Sunday's session reschedule request must be made on or before the previous Thursday. There will be every attempt to find an appointment time to accommodate your reschedule request but it cannot guarantee that space is available for your requested reschedule. Without the 24 hours in advance written reschedule request and new appointment time you will be responsible for the full session fee. Your card on file will be charged on the same business day of your missed session. Failure to arrive on time to a session means you will still be charged for the full session fee regardless of your arrival time to the session. Keep in mind this office is not responsible to remind the client of the consistency policy before charging for missed sessions or no-shows.
You will receive two waiver cancellations per year free of charge of no show or cancelation no reschedule fees. You may use these at any time. If the clinician has to cancel a session with you: you will not be charged. If you find you are in need of an extended break from therapy due to unplanned circumstances or other situations that arise it will be discussed on an individual basis at the clinician's discretion. If your break is longer than 3 weeks they will have the option to be removed from the schedule and reschedule the week of your return.
• By completing and signing this Financial Agreement, you are indicating that you understand and agree to provide a valid credit card number, expiration date, zip code and cvv number for payment of future sessions, appointments or other fees. This is regardless of the choice to use Square or Stripe.
• Your signature indicates you understand that if you do not attend a scheduled appointment your credit card, Square or Stripe account will be charged the regular full session fee unless you reschedule your session during the same business week at least 48 hours in advance. If you do not post payment on Square or Stripe within 48 hours your card on file will be charged.
• Your signature indicates that you understand that you, not an insurance company or other 3rd party payer, will be paying for your sessions, and any missed.
• Your credit card number will be kept on file throughout treatment, (even if you use Square or Stripe). You will be charged each time an appointment is completed (either by card or Square or Stripe) and invoices may be sent to the email through the client portal. Payments are expected at the time of service or in advance of service.
• Your signature indicates that you may be charged for other services such as, extended phone calls, consultation on your behalf, and other services rendered on your behalf. These charges will be discussed with you ahead of the services provided.
• Clients may incur and are responsible for payment of additional charges, if applicable. - After 30 days, balances are subject to be turned over to our collection agency. The patient will be responsible for all collection fees, attorney fees, and court costs.