disclosures/privacy practices/FAQ
Informed Consent for Psychotherapy
General information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This Consent will provide a clear framework for our work together. Feel free to discuss any of this with the therapist.
The Therapeutic Process
You have taken a very important step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at time, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstances will change. The therapist will support you and do his/her very best to understand you and repeating patterns, as well as to help you clarify what it is you want for yourself.
Confidentiality
The session content and all relevant materials to treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/ persons, subject to the professional judgment of the therapist. Limitations of such client held privilege of confidentiality exist as identified below.
1.If a client threatens or attempts to commit suicide or otherwise conducts him/herself in a way where there is a substantial risk of incurring serious bodily harm.
2.If a client threatens bodily harm or death to another person.
3.If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years old.
4.Suspicions as states above in the case of an elderly person or vulnerable adult who may be subjected to these abuses.
5.Suspected neglect of the parties named in items #3 and#4.
6.If a court of law issues a legitimate court order, subject to HIPAA and Michigan law, and as determined in the sole professional judgment of the therapist. Occasionally therapist may need to consult with other professionals in their area of expertise in order to provide the best treatment for me. Information about me may be shared in this context without using my name or identifying information.
Using Insurance for Services
I understand that in choosing to use my insurance for services I give Azalea Therapy and Consultation Services permission to bill my insurance company for services rendered to me or my dependents and to release any information such as diagnosis, treatment plans, and Protected Health Information as necessary to obtain payment for services, and as allowed by HIPAA. I agree to disclose all relevant and current insurance information both completely and accurately including any changes to my insurance coverage. I understand that it is my responsibility to understand my insurance benefits, including limitations and/or exclusions, deductibles, co-pays, yearly maximums, and authorizations for treatment as applicable. Staff may try to help me navigate my insurance benefits, but ultimately, I am responsible for understanding my benefits.
Current Fee Schedule:
Intake appointment $180
45 minute session $150, 60 minute session $180
Group Therapy $50
Couples Therapy $150/session
Paperwork completion, External Communication (includes letter writing) $40/15 minutes
IEP, School, or other external appointments $180/hour
I understand that out of pocket expenses that are not covered by my insurance company are my responsibility to pay and fees for services including co-pays are to be paid at the time of services. If my insurance company does not cover any fees for the services my dependent (s) or I have received, I accept full responsibility for these costs. If maximum insurance benefits have been reached, I will be fully responsible for any fees for services subsequently rendered to my dependent (s) or myself. I understand that many insurance companies will not and do not cover two mental health appointments on the same day and that I will be charged directly for one of the two appointments if this occurs.
•If I am late to an appointment by more than 10 minutes, I am aware that appointment may be on a cash-pay basis and I am liable for all charges at the time of the appointment.
•If I do not show to an appointment or cancel within 24 hours of the appointment, I am aware that I will be charged the fee for the appointment.
•If a diagnostic evaluation or treatment is terminated by choice or because of violation of client/ therapist agreement, I agree to pay all outstanding fees at time of termination.
•I understand that telephone consultations over 10 minutes may be subject to a charge, which my insurance will not always cover, in which case I will be financially responsible for the consultation. I agree to allow Azalea Therapy and Consultation Services to bill insurance for phone sessions, if covered.
•I understand that I will be made aware of any potential fees for any additional services requested and will have the opportunity to consent prior to receiving these services.
All services not covered by insurance are due and must be paid at the time of the appointment.
I understand that unpaid balances over $500 and/or 90 days old may automatically be transferred to a collection agency unless formal written payment arrangements have been made with Azalea Therapy and Consultation Services. I understand that defaulting on any payment arrangement will lead to my account going immediately back into a collection status. I understand that treatment could be suspended for nonpayment and referrals will be provided.
Email Communications: By providing my therapist with my email, I acknowledge that my email address is personal to me and I authorize the therapist to communicate with me via email.I acknowledge that communications the therapist or his/her employees, contractors and staff via email are not secure, encrypted or confidential methods of communication. As such, I expressly waive the therapist’s and Azalea Therapy and Consultation Services’ obligation to guarantee security and confidentiality with respect to email correspondence. I acknowledge that all such communications may become a part of my medical record. I agree that email is not an appropriate means of communication regarding emergency or other time-sensitive issues or for communications regarding sensitive information. If I do not receive a timely response from the therapist to an email message I send, I agree to use another means of communication to contact my therapist. Neither my therapist, Azalea Therapy and Consultation Services nor its employees, contractors or staff will be liable to me for any loss, cost, injury, or expense caused by, or resulting from, a delay in responding to me, technical failures, interception of emails by a third party, or my failure to comply with the above guidelines regarding email communications.
Emergency Contact Person: My signature below evidences my agreement that if I have designated an emergency contact person, I consent and agree that such emergency contact person is involved in my care and that the therapist and Azalea Therapy and Consultation Services, its employees, contractors and providers may communicate with my designated emergency contact person to discuss my care, treatment and payments in compliance with applicable laws. My signature below further evidences that I am aware and agree that my decision to designate an emergency contact person is optional and that treatment will not be withheld by or conditioned upon my designation of an emergency contact person. My signature below evidences I acknowledge that regardless of whether I choose to designate an emergency contact person, my therapist and Azalea Therapy and Consultation Services and its employees, contractors and providers may make certain disclosures pertaining to my information, care, treatment and payment if such disclosures are permitted or required by applicable laws. I understand that I may change or revoke the emergency contact person that I designate (if any) in writing and that my revocation will not be effective for actions already taken by the therapist or that are in progress and will only be prospectively effective.
Contact Outside of Therapy: If we see each other accidentally outside of the therapy office, I understand that you will not acknowledge me unless I acknowledge you first. My right to privacy and confidentiality is of the upmost importance to the therapist and does not wish to jeopardize my privacy. However, if I acknowledge you first, the therapist may be more than happy to speak briefly with me, but he/she feels it appropriate not to engage in any lengthy discussions in public or outside the therapy office.
NOTICE OF PRIVACY PRACTICES
A.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. This Notice of Privacy Practices (Notice) applies to all information about care that you receive from Azalea Therapy and Consultation Services, who may use and share your health information for treatment, payment or health care operations as described in this Notice.
B.I AM REQUIRED TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION(PHI). I am committed to protecting the privacy of your health information, called “protected health information” or “PHI”. PHI is information that can be used to identify you that I have created or received about your past, present, or future health or condition, the provision of health care to you, or payment for health care provided to you. I am required to provide you with this notice to explain my privacy practices and how, when, and why I use and disclose your PHI. In general, I may not use or disclose any more of your PHI than is necessary to accomplish the purpose of the use or disclosure, although there are some exceptions. I am legally required to follow the privacy practices described in this notice and notify you following a breach of your unsecured PHI.
C.HOW I USE AND DISCLOSE YOUR PHI. I use and disclose PHI for different reasons, and some require your prior specific authorization. The different categories of my uses and disclosures are described below, with examples of each.
1.Uses and Disclosures Relating to Treatment, Payment or Health Care Operations Do Not Require Your Consent.
a. For Treatment. I may use and disclose your PHI to other health care providers who provide health care services to you or who are involved in your care. For example, if you are being treated for depression, I may disclose your PHI to your treating physician to coordinate your care.
b. To Obtain Payment. I may use and disclose your PHI to bill and collect payment for treatment services provided to you. For example, I may use some of your PHI and disclose it to your health plan for payment or for reimbursement purposes.
c. For Health Care Operations. I may use and disclose your PHI in the operation of Azalea Therapy and Consultation Services. For example, I may use your PHI to review the care provided to you or procedures involved in your care.
2.Certain Other Uses and Disclosures That Do Not Require Your Consent. Imay also use and disclose your PHI:
a. When disclosure is required by federal, state or local law,judicial or administrative proceedings, or law enforcement. For example, I make disclosures when a law requires that I report information to government agencies and law enforcement personnel about victims of abuse, neglect or domestic violence, or when ordered in a judicial or administrative proceeding. b. For public health activities. For example, I must report to government officials in charge of collecting specific information related to births,deaths,and certain diseases. PHI also may be in connection with occupational health and safety or worker’s compensation matters.
c. For health oversight activities. For example, I will provide information to government officials to conduct an investigation or inspection of a health care provider or organization.
d. To avoid harm. To avoid a serious threat to the health or safety of a person or the public, I may provide PHI to law enforcement personnel or persons able to prevent or lessen the potential harm.
e. For workers’ compensation reasons. I may provide PHI to comply with workers’ compensation laws.
f. To provide appointment reminders and health-related benefits or services. I may use PHI to provide appointment reminders. I may also give you information about treatment alternatives, or other health care services or benefits I provide.
3.Uses and Disclosures to Which You Have an Opportunity to Object.
a. Disclosure to family, friends, or others. I may provide your PHI to a family member, friend or other persons involved in your care or responsible for the payment for your health care, unless you object.
b. Applicable Michigan Law. My use and disclosure of PHI must comply not only with federal privacy regulations but also with applicable Federal and Michigan law. Michigan law and/or Federal Regulations place certain additional restrictions on the use and disclosure of PHI for mental health, substance abuse, and HIV/AIDS conditions. In some instances, your specific authorization may be required.
c. All Other Uses and Disclosures Require Your Prior Written Authorization. In situations not covered by this Notice, your written authorization is needed before using or disclosing your PHI, including most uses and disclosures of psychotherapy notes, (unless otherwise specified by law. Your authorization can always be revoked in writing (but it would not apply to prior disclosures made based on your initial authorization).
D.YOUR RIGHTS REGARDING YOUR PHI. You have the following rights with respect to your PHI:
1.The Right to Request Restrictions on Uses and Disclosures of Your PHI. You have the right to ask me to limit how I use and disclose your PHI for treatment, payment or health care operations. This request must be in writing. I am not required to agree to your restriction request, but if I do, I will honor my agreement except in cases of an emergency or in cases where I am legally required or allowed to make a use or disclosure. I am required to agree to a written request to restrict disclosure of your PHI to a health plan if the disclosure is for payment or health care operations and is not otherwise required by law, and pertains to treatment services you have paid in full and out of pocket. Also, you may request me to limit PHI disclosures to family members, other relatives, or close friends involved in your care or payment for it.
2.The Right to Request Confidential Communications Involving Your PHI. You can ask in writing to send information to you in a certain way/location. For example, you can request I mail PHI to a P. O. Box rather than your home. I must agree so long as I can easily provide it in the format you requested.
3.The Right to Receive Copies of Your PHI. In most cases you have the right to receive copies of your PHI, such as health or billing records, used by me to make decisions about you. You must make the request in writing. I will respond within 30 days after receiving your written request, and I may charge a reasonable fee. In certain situations, I may deny your request, but I will do so in writing, and I will provide my reasons for the denial and explain your right to have the denial reviewed.
4.The Right to Get a List of the Disclosures I Have Made. You have the right to get a list of instances I have disclosed your PHI ( an Accounting of Disclosures.) This right does not apply to disclosures made for treatment, payment or health care operations, disclosures made to you or to others involved in your care, disclosures made with your authorization, or disclosures made for law enforcement purposes. Your request for an Accounting of Disclosures must be made in writing to the person and address below. I will respond within 60 days of receiving your request by providing a list of disclosures made within the last six years from the receipt date of your request, unless a shorter time period is requested. If you make more than one request in the same year, I may charge a fee.
5.The Right to Amend or Update Your PHI. If you believe your PHI is incorrect or incomplete, you have the right to request me to add to or amend the existing information. Your request must be in writing and must include the reason for your request. I will respond within 60 days of receiving your request. I may deny your request in writing if the PHI (i) is correct and complete, (ii) was not created by me, (iii) is not allowed to be disclosed, or (iv) is not part of my records. My denial will include the reason(s) for the denial and will explain your right to file a written statement of disagreement. If you don’t file a written statement of disagreement, you have the right to request that your amendment request and my denial be attached to your PHI. If your amendment request is approved, I will make the change to your PHI. An amendment may take several forms, such as an explanatory statement added to your record.
6.The Right to a Copy of this Notice. You have a right to request a paper copy of this Notice be mailed to you. It is also available at: https://azaleatherapy.com
E.WHO YOU CAN CONTACT FOR INFORMATION ABOUT THIS NOTICE OR MY PRIVACY PRACTICES. If you have questions about this Notice or complaints about my privacy practices, or if you would like to know how to file a complaint with the Office for Civil Rights of the U.S. Department of Health and Human Services, you can contact me at 734-787-5872. You will not be penalized for filing your complaint. Written complaints must be submitted to : Laura Jennings, LMSW, PLLC 5840 North Canton Center Road Suite 224 Canton, MI 48187. I may change my privacy practices at any time. Before I make an important change, I will revise this Notice and post it in my office and on my website at: https://azaleatherapy.com.
F.EFFECTIVE DATE OF THIS NOTICE: September 24, 2020, revised September 24, 2020.
Good Faith Estimate
OMB Control #: 0938-1401
You have the right to receive a “Good Faith Estimate” (GFE) explaining how much your medical care will cost.
Under the law, health care providers need to give patients who do not have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a GFE for the total expected cost of any services you are paying for out-of-pocket
Make sure your health care provider gives you the GFE in writing at least 1 business day before your medical service. You can also ask your provider, or any provider you choose, for a GFE before you schedule a service.
If you receive a bill that is at least $400.00 more than your GFE, you can dispute the bill.
Make sure you save a copy or picture of your Good Faith Estimate.
For questions, contact Laura Jennings at 734-787-5872. You can also visit www.cms.gov/nosurprises.
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network facility, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you, unless you give written consent and give up your protections.
You’re never required to give up your protections from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization)
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact the State of MI Department of Insurance and Financial Services at 833-ASK-DIFS (833-275-3437).
Visit www.cms.gov/nosurprises for more information about your rights under federal law.