INFORMED CONSENT TO TREATMENT

AND OFFICE POLICIES

Welcome! This document contains important information about my professional services and business policies. Please read it carefully, and write down any questions you might have, so that we can discuss them at our next meeting. When you sign this document, it will represent the acknowledgement and acceptance of the informed consent and office policies.

Sessions

Our sessions last 50 minutes, per session. Your commitment to the psychotherapeutic process, and consistent attendance at your sessions, contributes greatly to a successful outcome. 

The hour(s) scheduled for you will be reserved for you and will be charged, barring extraordinary circumstances or advance mutual agreement.  

However, if you need to miss a session, I will try to find another time to reschedule your appointment during the same week, and I will apply your session fee to that session. Do be aware, it will not always be possible to find a mutually available time to reschedule a session.

If you are late for a session, we will end at the scheduled time, and you will still be responsible for the full price of the session.

Professional Fees

My hourly fee is $175, unless otherwise negotiated. In addition to scheduled appointments, I charge this amount for most other professional services you may need, though I will break down the hourly cost if I work for periods of less than one hour. Other services may include report writing, telephone conversations lasting longer than 5 minutes, attendance at meetings with other professionals you have authorized, preparation of records or treatment summaries, and the time spent performing any other service you may request of me.

If you become involved in legal proceedings that require my participation, you will be expected to pay for my professional time even if I am called to testify by another party. Because of the difficulty of legal involvement, I charge $200 per hour for preparation and attendance at any legal proceeding.

Sliding Scale Rate Agreements

Sliding scale rates may be negotiated on an individual basis, and are based wholly on financial need. This courtesy is extended in order to make regular weekly attendance at sessions more manageable for people with financial hardship. Regular participation in weekly individual or multiple scheduled sessions, therefore, is a primary condition for honoring sliding scale agreements, and missed sessions will be a condition for forfeiting that agreement. Sliding scale rates are subject to regular check-ins and adjustments, as appropriate.

Billing and Payments

All fees are payable and collected in advance, or at the beginning, of each session. I accept cash, check, or ACH transfer through Venmo @DrPamelaAlbro.

Unpaid balances will not be held. If payment is not made in full at the time of your session, any pre-negotiated rate agreements or scheduled sessions will not be reserved until full payment is received and cleared.

Bank charges on returned checks are your responsibility. In circumstances of unusual financial hardship, I may be willing to negotiate a fee adjustment or payment installment plan. Upon request, you will be provided with a monthly statement, and you can use this form to submit for reimbursement from you insurance provider.

If your account has not been paid for more than 60 days and we have not agreed upon a payment plan, I have the option of using legal means to secure payment. This may involve hiring a collection agency or going through small claims court. If such legal action is necessary, its costs will be included in the claim. In the case of collection, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

Confidentiality

Confidentiality is a special part of the psychotherapeutic relationship, and critical to the therapeutic process. In general, the privacy of all communications, between patient and psychotherapist, are protected by law. I can only release information about our work together with your written authorization. 

However, there are a few situations in which I am legally obligated to take action, and file a report with the appropriate state agency, even if I have to reveal some information about a patient/patient's treatment.  These exceptions to confidentiality include:

  • If I have reasonable cause to believe that a client is in such mental or emotional distress as to be a danger to him or herself, I may be obligated to take protective action, including seeking hospitalization or contacting family members or others who can help provide protection.
  • If a client communicates a serious threat of physical violence against an identifiable victim, I must take protective actions, including notifying the potential victim and the police. I may also seek hospitalization of the client, or contact others who can assist in protecting the victim.
  • If I have knowledge that a child under 18 has been the victim of physical abuse, sexual abuse or neglect, the law requires that I file a report to the Department of Child and Family Services. I may also make a report if I know or reasonably suspect that mental suffering has been inflicted on a child or that his or her emotional well-being is endangered in any other way.
  • If I have knowledge of physical abuse, abandonment, abduction, isolation or financial abuse or neglect of an elder or adult dependent, the law requires that I file a report the appropriate government agency. 
  • I may seek consultation with other health and mental health professionals at certain times. During a consultation, I make every effort to avoid revealing the identity of my client. The professionals with whom I consult are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that they are important to our work together. 
  • If you are involved in a court proceeding and a request is made for information about the professional service that I have provided you and/or the records thereof, such information is protected by the psychotherapist/client privilege law. I cannot provide any information unless authorized by you, your legal representative, or ordered by the court.
  • If you file a worker’s compensation claim, I must, upon appropriate request, disclose information relevant to your condition, to the worker’s compensation insurer.
  • Disclosures required by health insurers are discussed elsewhere in this agreement.

If such a situation does occur, I will make every effort to fully discuss it with you before taking any action.

If, during the course of our work together, my physical safety is seriously threatened, I will both terminate therapy and provide the information necessary for the protection of the appropriate authorities.

NOTE: It is also important to be aware of other potential limits to confidentiality, including communication via cell phones, faxes, and emails.

“No-Secrets” Policy (Couples)

If you are a couple in treatment, I consider the couple to be the “patient.”  For instance, if there is a request for treatment records of the couple, I will seek authorization from all members before releasing confidential information to third parties. In most cases you will both/all be present for our sessions and nothing is shared that both/all of you will not hear. When not all members are present for a session, however, it will be assumed that whatever is shared in the session may be shared with all other members (either by the individual or by me as appropriate) unless explicitly agreed otherwise by all parties. If you feel it necessary to speak about matters that are not to be shared with your partner, consider consulting with an individual therapist.

Professional Records

The laws and standards of the psychology profession require that I keep professional records. These are maintained, under lock and key, for a minimum of seven years, after termination of services.  For information about your right to access your records, please see the Notice of Privacy Practices

Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers, and I recommend that you review them in my presence so that we can discuss their contents. If you wish to see your records, you will be charged my normal hourly fee (unless we agree or have agreed to a different fee) for any professional time spent in responding to information requests.

Termination

The length of your treatment and the timing of eventual termination depend on your particular process, progress, and goals.  The decision to terminate may be initiated by you, by me, or by our mutual agreement. My goal is to make this process as mutual as possible.

Please be aware that I may terminate treatment if payment is not timely, if a pattern of frequent cancellations should develop, or if other behaviors are compromising the effectiveness of treatment. I may also initiate termination if some problem arises that is not within the scope of my practice or competence.

Dispute Resolution

All disputes arising out of or in relation to this agreement to provide psychological 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. 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 accordance with the rules of the American Arbitration Association in effect at the time the demand for arbitration is filed. The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney’s fee.

NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information.  Please review it carefully.

 The Health Insurance Portability and Accountability Act of 1996 (HIPPA) is a federal program that protects the privacy of health care information by setting standards for privacy and security of individually identifiable information.

The services you are receiving here concern your psychological status, a private and intimate aspect of your life.  Thus, protecting your privacy is of utmost importance. This notice explains how, when and why I may use/and or disclose your records, which are known under the HIPAA legislation as “Protected Health Information” (PHI). Except in specified circumstances, your PHI will not be released to anyone. When disclosure is necessary under the law, only the minimum amount of use and/or disclosure of your PHI necessary to accomplish the purpose of the use and/or disclosure will occur.  I reserve the right to change the terms of the Notice of Privacy Practices and make provisions effective for all PHI I maintain.  In the event that a revision is made, I will communicate this by providing the revised Notice of Privacy Practices upon request and having a copy for individuals to take with them.

Safeguards Governing Your Protected Health Information

Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for health care is considered PHI. Your PHI results from your treatment, payment, and other related health care operations. PHI may also be received from other sources, i.e. other health care providers, attorneys, etc. You and your PHI receive certain protections under the law.

If you are receiving any type of psychotherapy service, your PHI is typically limited to basic session and billing information placed in a file in my office. Only this office will have access those files. Clinical notes taken after session are known as Psychotherapy Notes and are not part of your PHI. Except in unusual, emergency situations described below, your PHI will only be released with your specific Authorization.

How Your Protected Health Information may be Used or Disclosed

I appreciate the opportunity to provide the highest quality health care services to you and value the trust that you have placed in me in choosing to visit my practice.  I respect that trust by exercising competent professional judgment in my decision-making regarding the use of you healthcare information.  In order for me to provide care to you, it is necessary to create, receive, and communicate medical information about you.  This may involve:

In accordance with HIPAA and its Privacy Rule (Rule), your PHI may be used and disclosed in the following, specified circumstances:

A. Uses and/or disclosures related to your treatment (T), the payment for services you received (P), or for health care operations (O):

1.  For Treatment (T): Your PHI may be shared with other health care providers (psychologists, psychiatrists, physicians, nurses, and other health care personnel) involved in providing health care services to you.  However, although such uses/disclosures are permissible under the Rule, generally they will only occur with your specific Authorization.

2.  For Payment (P): Your PHI may be used and/or disclosed for billing and collection activities without your specific Authorization.

3.  For Health Care Operations (O): Your PHI may be used and/or disclosed in the course of operating the various business functions of my office, without your specific Authorization.

B. Uses and/or disclosures requiring your Authorization: Generally, the use and/or disclosure of you PHI for any purpose that falls outside of the definitions of treatment, payment and health care operations identified above will require your signed Authorization. If you grant your permission for such use and/or disclosure of your PHI, you retain the right to revoke your Authorization at any time except to the extent that a disclosure might already have been made.

C.  Uses and/or disclosures not requiring your Authorization: The Rule provides that your PHI may be used and/or disclosed without your Authorization when required by existing law in the following circumstances:

1.  Reporting child, dependent adult, and/or elder abuse or neglect: I may use and/or disclose your PHI in cases of suspected child abuse or neglect; suspect dependent adult abuse or neglect; and suspected elder abuse or neglect.  Such reporting may be to social service and/or law enforcement agencies as provided by law.

2.   Judicial and administrative proceedings: I may use and/or disclose your PHI in response to an order of a court or administrative tribunal, a warrant, or other lawful process.

3.   To avert a serious threat to health or safety: I may use and/or disclose your PHI in order to avert a serious threat to health or safety. For example, if I reasonably believed you were at imminent risk of harming a person or property, or of hurting yourself, I am authorized to disclose your PHI to prevent such an act from occurring.

Your Rights Regarding Your Protected Health Information (PHI)

The HIPAA Privacy Rule grants you each of the following rights regarding your PHI:

A.  In general, you have the right to view your PHI or to obtain copies of it. You must request it in writing. Generally, you have the right to access your PHI according to the following timeframes: inspection within five business days of my receipt of your written request; a summary of your PHI within ten business days of my receipt of your written request; copies of your PHI within 15 days of my receipt of your written notice; and summary of your PHI within 30 days of receipt of your written notice when extenuating circumstances exist. You will receive a response from me within 30 days of submission of your written request. Under certain circumstances, such as if release of your PHI would be dangerous to you or another person, I may deny your request and offer to provide a summary instead. If your request is denied, I will give you reasons for the denial in writing. You have a right to have the denial reviewed. If you ask for copies of your PHI, you will be charged not more than $0.25 per page. I may determine it is appropriate to provide you with a summary or explanation of your PHI, but only if you agree in advance to it as well as to the cost.

B.  You have the right to ask that I limit uses and disclosures of your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I 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 I am legally required or permitted to make.

C.  It is your right to ask that your PHI be sent to you at an alternate address or by an alternate method, e.g., email. I am obliged to agree to your request providing that I can give you the PHI in the format you requested without undue inconvenience.

D.  You are entitled to a list of disclosures of your PHI that I have made in the past six years. The list will not include uses or disclosures to which you have already consented, e.g., those for treatment, payment, or health care operations. I will respond to your request for an account of disclosures within 60 days of receiving your request. The list will include the date of the disclosure, the person or entity to whom PHI was disclosed (including the address if known), a description of the information disclosed, and the reason for the disclosure. This will provided to you at no cost, unless you make more than one request in the same year, in which case you will be charged a reasonable sum based on a set fee for each additional request.

E.  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 I 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 my receipt of your request. Your request may be denied if it is determined that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written or created by someone other than me. Any denial will be in writing and will state the reasons for the denial. It will 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 my denial be attached to any future disclosures of your PHI. If your request is approved, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and will advise all others who need to know about the changes(s) to your PHI.

F.  You have the right to get this notice by email. You have the right to request a paper copy of it as well.

How To Complain about These Privacy Practices

I am the HIPAA compliance officer for this psychology office. If you believe that my office has violated your individual privacy rights, or if you object to a decision made about access to your PHI, you are entitled to submit a written complaint to me. Your written complaint must name the person or entity that is the subject of your complaint and describe the acts and/or omissions you believe to be in violation of the provisions outlined in this Notice of Privacy Practices. If you prefer, you may file your written complaint with the Secretary of the U.S. Department of Health and Human Services (Secretary) at 200 Independence Avenue S.W., Washington, D.C. 20201. However, any complaint you file must be received by me, or filed with the Secretary, within 180 days of when you knew, or should have known, the act or omission occurred. We will take no retaliatory action against you if you make such a complaint. However, psychotherapy may need to be discontinued. If this happens, we will give you a referral to another therapist or clinic.