Forms

If you're a new client, please complete the following forms and bring them to your first therapy session.

For Therapists, please complete the following forms:

Client Intake Form - This form will upload once completed

Adult Behavioral Health Questionnaire - This form will upload once completed.

PHQ-9 Questionnaire - This form will upload once completed.

Limits of Confidentiality/Therapy Cancellation Policy - Please print and complete prior to your first appointment.

For Nurse Practitioner, please complete these forms:

Client Intake Form - This form will upload once completed.

Nurse Practitioner Behavioral Health Questionnaire - This form will upload once completed.

Controlled Substances Consent Form - Please download and complete prior to your first appointment.

Release of Information - Please download and complete prior to your first appointment.

Limits of Confidentiality/Therapy Cancellation Policy - Please download and complete prior to your first appointment.

Appointment Reminder Form - Please download and complete prior to your first appointment

Additional Questionnaires- Please download and complete prior to your first appointment

Standard Notice for Non-Participating (Fee for Service) Clients - Please download and completion prior to first appointment.

Required Forms for BOTH Therapists and Nurse Practitioner:

Credit Card Pre-Authorization Form - Please download and complete prior to your first appointment.

Payment Agreement/Assignment of Benefits - Please download and sign prior to your first appointment.

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

• Authorization to Disclose Information Form

Note: To download Adobe Acrobat Reader for free, Click here.

Please read the following information about HIPPA and other important information prior to making an appointment.

HIPPA AND OTHER IMPORTANT INFORMATION FOR NEW CLIENTS

Each of the therapists at The Psychological Cooperative at Malec and Associates is an independent professional. Clinicians at the Cooperative at Malec and Associates include Psychologists, Doctoral Nurse Practitioners, Licensed Clinical Social Workers, Licensed Professional Counselors, Registered Dietician and School Psychologist.  All disciplines require the minimum of a master’s degree in their respective fields; hundreds, if not thousands of hours of supervised experience; successful completion of national credentialing tests; ongoing continuing education in the field; and abiding by the rules and ethics of their respective licensing boards and professional organizations. All therapists at the Psychological Cooperative at Malec and Associates abide by the following information. Please read the following information thoroughly. Your therapist may require you to sign a form saying that you have reviewed and understand the following. You will have the opportunity to ask questions before you sign any forms. Please feel free to make copies for yourself. This page answers some questions clients often ask about any therapy practice. It is important that you know how we will work together. Our work will be most helpful to you when you have a clear idea of what we are trying to do. It will cover the following information:

• The risks and benefits of therapy
• Consultations
• What you can expect from the therapy relationship
• Confidentiality
• About your appointments
• Fees and other money matters
• Electronic payment communication disclosure
• Health insurance coverage
• Contacting your therapist and emergency contact information
• Electronic records disclosure
• Principles & complaint procedures
• Privacy practices

The Risks and Benefits of Therapy

As with any powerful treatment, there are some risks as well as many benefits with therapy. You should think about both the benefits and risks when making any treatment decisions. For example, in therapy, there is a risk that clients will, for a time, have uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other negative feelings. Clients may recall unpleasant memories. These feelings or memories may bother a client at work or in school. In addition, some people in your community may mistakenly view anyone in therapy as weak, or perhaps as seriously disturbed or even dangerous. Also, clients in therapy may have problems with people important to them. Family secrets may be told. Therapy may disrupt a marital relationship and sometimes may even lead to a divorce. Sometimes, too, a client’s problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you.

While you consider these risks, you should know also that the benefits of therapy have been shown by scientists in hundreds of well-designed research studies. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to talk things out fully until their feelings are relieved or the problems are solved. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as persons, in their close relationships, in their work or schooling, and in the ability to enjoy their lives.

We do not take on clients we do not think we can help. Therefore, we will enter a therapeutic relationship with optimism about your progress. 

Consultations

If you could benefit from a treatment your therapist cannot provide, we will help you to get to the proper therapist or facility. You have a right to ask about such other treatments, their risks, and their benefits. Based on what is learned about your problems, a medical exam or use of medication may be recommended. If this is the case, the reasons will be discussed fully with you, so that you can decide what is best. If you are treated by another professional, your therapist will coordinate services with your medical doctor.

If for some reason treatment is not going well, it might be suggested that you see another therapist or another professional in addition to your therapist. As responsible persons and ethical therapists, we cannot continue to treat you if the treatment is not working for you. If you wish for another professional’s opinion at any time, or wish to talk with another therapist, we will help you find a qualified person and will provide him or her with the information needed. 

What to Expect from the Therapy  Relationship

As professionals, we will use our best knowledge and skills to help you. This includes following the standards of our professions. In your best interests, these standards put limits on the relationship between a therapist and a client, and we will abide by these. Let us explain these limits, so you will not think they are personal responses to you.

First, we are licensed and trained to practice psychology and/or counseling—not law, medicine (with the exception of Nurse Practitioners), finance, or any other profession. We are not able to give you good advice from these other professional viewpoints.

Second, state laws and the rules of the professional organizations require us to keep what you tell us confidential (that is, private). You can trust your therapist not to tell anyone else what you talk about, except in certain limited situations. We explain what those are in the “About Confidentiality” section below. Here we want to explain that we try not to reveal who our clients are. This is part of the effort to maintain your privacy. If we meet on the street or socially, your therapist may not say hello or talk to you very much. This behavior will not be a personal reaction to you, but a way to maintain the confidentiality of our relationship.

Third, in your best interest, and following the American Psychological Association’s standards, your therapist can only be your therapist. Your therapist cannot have any other role in your life. He or she cannot, now or ever, be a close friend or socialize with any of his or her clients. She or he cannot be a therapist to someone who is already a friend, can never have a sexual or romantic relationship with any client during, or after, the course of therapy. He or she cannot have a business relationship with any clients,

other than the therapy relationship. Even though you might invite your therapist, he or she will not attend your family gatherings, such as parties or weddings. As your therapist, he or she will not celebrate holidays or give you gifts; may not notice or recall your birthday; and may not receive any of your gifts eagerly. 

 About Confidentiality

We will treat with great care all the information you share. It is your legal right that our sessions and the records about you be kept private. That is why you will be asked to sign a “release-of-records” form before your therapist can talk about you or send records about you to anyone else. In general, your therapist will tell no one what you talk about in therapy. In fact, he/she will not even reveal that you are receiving treatment from him or her.

In all but a few rare situations, your confidentiality (that is, your privacy) is protected by state law and by the rules of our professions. Here are the most common cases in which confidentiality is NOT protected:

1. If you were sent to therapy by a court or an employer for evaluation or treatment, the court or employer expects a report from the therapist. If this is your situation, please talk with your therapist before you talk about anything you do not want the court or your employer to know. You have a right to discuss only what you are comfortable discussing.

2. Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court that you are seeing a therapist, the therapist may then be ordered to show the court your therapy records. Please consult your lawyer about these issues.

3. If you make a serious threat to harm yourself or another person, the law requires a therapist to try to protect you or that other person. This usually means telling others about the threat. We cannot promise never to tell others about threats you make.

4. Psychologists are state mandated to report driving impairments.

5. If a therapist has reason to suspect, on the basis of his/her professional judgment, that a child is or has been abused, the therapist is required to report his/her suspicions to the authority or government agency vested to conduct child-abuse investigations. The therapist is required to make such reports even if he/she does not see the child in his/her professional capacity. Therapists are mandated to report suspected child abuse if anyone aged 14 or older tells the therapist that he or she committed child abuse, even if the child is no longer in danger. Therapists are also mandated to report suspected

child abuse if anyone tells the therapist that he or she knows of any child who is currently being abused.

There are two situations in which your therapist might talk about part of your case with another therapist. We ask now for your understanding and agreement in these two situations.

First, when your therapist is away from the office for a few days, a trusted fellow therapist “covers” for the practice. This therapist will be available to you in emergencies. Therefore, he or she may need to know about you. Of course, this therapist is bound by the same laws and rules as your therapist to protect your confidentiality.

Second, sometimes therapists consult with other therapists or other professionals about their clients. This helps in giving high-quality treatment. These consultants are also required to keep your information private. Your name will never be given to them, and they will be told only as much as they need to know to understand your situation.

Except for the situations described above, the office staff and therapists will always maintain your privacy. We also ask you not to disclose the name or identity of any other client being seen in this office. Our office staff makes every effort to keep the names and records of clients private. Our staff and we will try never to use your name on the telephone, if clients in the office can overhear it. All staff members who see your records have been trained in how to keep records confidential. If your records need to be seen by another professional, or anyone else, your therapist will discuss it with you. If you agree to share these records, you will need to sign a release form. This form states exactly what information is to be shared, with whom, and why, and it also sets time limits. You may read this form at any time. If you have questions, please ask your therapist. It is the office policy to destroy clients’ records 10 years after the end of our therapy. Until then, your case records will be stored in a safe place. If your therapist must discontinue your therapy because of illness, disability, or other presently unforeseen circumstances, we ask you to agree to the transfer of your records to another therapist who will assure their confidentiality, preservation, and appropriate access. If we do family or couple therapy (where there is more than one client), and you want to have the records of this therapy sent to anyone, all of the adults present will have to sign a release.

As part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and treatment methods. It will become part of your permanent medical record. We will let you know if this should occur and what the company has asked for. Please understand that we have no control over how these

records are handled at the insurance company. Our policy is to provide only as much information as the insurance company will need to pay your benefits.

You can review your own records in your therapist’s files at any time. You may add to them or correct them, and you can have copies of them. We ask you to understand and agree that you may not examine records created by anyone else that have been sent to us. In some very rare situations, your therapist may temporarily remove parts of your records before you see them. This would happen if we believe that the information will be harmful to you, but your therapist will discuss this with you. 

 About Your Appointments

The very first time your therapist meets with you, it will likely be for an hour. Following this, we will usually meet for either a 45 or 55-minute session once or twice a week, then less often. We attempt to give you a few week’s notice of upcoming time out of the office (for vacation, conferences, etc). An appointment is a commitment to our work. We agree to meet here and to be on time. If your therapist is ever unable to start on time, we ask your understanding. We also assure you that you will receive the full time agreed to. If you are late, we will probably be unable to meet for the full time, because it is likely that another appointment will be scheduled after yours.

A cancelled appointment delays our work. Your therapist considers your meetings to be very important and asks you to do the same. Please try not to miss sessions if you can possibly help it. When you must cancel, please give us at least a week’s notice. Your session time is reserved for you. We are rarely able to fill a cancelled session unless we know a week in advance. If you do not show up for an appointment or do not give 24 hour’s notice, we will have to charge you for the lost time. Your insurance will not cover this charge.

We request that you do not bring children with you if they are young and need babysitting or supervision, which we cannot provide. 

 Fees, Payments, and Billing

Payment for services is an important part of any professional relationship. This is even more true in therapy; one treatment goal is to make relationships and the duties and obligations they involve clear. You are responsible for seeing that our services are paid for. Meeting this responsibility shows your commitment and maturity.

Telephone consultations: Telephone consultations may be suitable or even needed at times in your therapy. If so, you will be charged your regular fee, prorated over the time

needed. Insurance companies may or may not pay for telephone consultations. Please consult your insurance policy. If your therapist needs to have long telephone conferences with other professionals as part of your treatment, you will be billed for these at the same rate as for regular therapy services. If you are concerned about any of this, please be sure to discuss it with your therapist in advance so we can set a policy that is comfortable. Of course, there is no charge for calls about appointments or similar business.

Reports: You will not be charged for time spent making routine reports to your insurance company. However, you will have to be billed for any extra-long or complex reports the company might require. The company will not cover this fee.

Other services: Charges for other services, such as hospital visits, consultations with other therapists, home visits, or any court-related services (such as consultations with lawyers, depositions, or attendance at courtroom proceedings) will be based on the time involved in providing the service at your regular fee schedule. Some services may require payment in advance.

We realize that our fees involve a substantial amount of money, although they are well in line with similar professionals’ charges. For you to get the best value for your money, we must work hard and well. We will assume that our agreed-upon fee-paying relationship will continue as long as services are provided to you. This will be assumed until you tell your therapist in person, by telephone, or by certified mail that you wish to end it. You have a responsibility to pay for any services you receive before you end the relationship. Because payment is expected at the time of your meetings, bills are typically not sent. However, if you and your therapist have agreed that you will be billed, we ask that the bill be paid within 5 days of when you get it. If you think you may have trouble paying your bills on time, please discuss this with your therapist. He or she will also raise the matter with you so we can arrive at a solution. If your unpaid balance becomes too high, you will be notified by mail. If it then remains unpaid, your therapist must stop therapy with you. Fees that continue unpaid after this may be turned over to our collection service. If there is any problem with our charges, our billing, your insurance, or any other money-related point, please bring it to your therapist’s attention. He or she will do the same with you. Such problems can interfere greatly with our work. They must be worked out openly and quickly. 

Electronic Payment Communications Disclosure

If you wish, you may pay fees electronically –  using a credit, debit or HSA card.  Our secure platform, Jituzu can accept many forms of payment.

Please Be Aware of the Following:

We have a duty to uphold your confidentiality, and thus we wish to make sure that your use of the above payment services is done as securely and privately as possible.

After using any of the above services to pay your fees, that service may send you receipts for payment by email or text message. These receipts will include your therapist’s  name, and would indicate that you have paid for a therapy session.

It is possible the receipt may be sent automatically, without first asking if you wish to receive the receipt. We are unable to control this in many cases, and we may not be able to control which email address or phone number your receipt is sent to.

So before using one of the above services to pay for your session(s), please think about these questions:

• At which email address or phone numbers have I received these kinds of receipts before?
• Are any of those addresses or phone numbers provided by my employer or school? If so, the employer or school will most likely be able to view the receipts that are sent to you.
• Are there any other parties with access to these addresses or phone numbers that should not be seeing these receipts? Would there be any danger if such a person discovered them?

In addition to these possible emails or text messages, payments made by credit card will appear on your credit card statement as being made to your therapist’s.   Please consider who might have access to your statements before making payments by credit card.

Health Savings Accounts and Flexible Spending Accounts

If you are using a Health Savings Account (HSA) or Flexible Spending Account (FSA) payment card, please be aware that even if your payment goes through and is authorized at the time that we run your card, there is a possibility that your payment could later be denied. In the event of this happening, you are responsible for ensuring that full payment is made by other means. 

Health Insurance Coverage

Many health insurance plans will help you pay for therapy and other services we offer. Because health insurance is written by many different companies, we cannot tell you

what your plan covers. Please read your plan’s booklet under coverage for “Outpatient Psychotherapy” or under “Behavioral Health Treatment.” Or call your employer’s benefits office to find out what you need to know.

If your health insurance will pay part of the fee, we will help you with your insurance claim forms. However, please keep two things in mind:

1. We had no role in deciding what your insurance covers. Your employer decided which, if any, services will be covered and how much you (and your therapist) will be paid. You are responsible for checking your insurance coverage, deductibles, payment rates, copayments, and so forth. Your insurance contract is between you and your company; it is not between your therapist and the insurance company.

2. You—not your insurance company or any other person or company—are responsible for paying the fees we agree upon. If you ask your therapist to bill a separated spouse, a relative, or an insurance company, and payment is not received on time, payment will be expected from you.

If you belong to a health maintenance organization (HMO) or have another kind of health insurance with managed care (including PPO and PSO policies), decisions about what kind of care you need and how much of it you can receive may be reviewed by the plan. The plan has rules, limits, and procedures that we should discuss. Please bring your health insurance plan’s description of services to one of our early meetings, so that we can talk about it and decide what to do.

We will provide information about you to your insurance company only with your informed and written consent. The information will be sent electronically, by mail, or by fax. Our office will try its best to maintain the privacy of your records, but we ask you not to hold us responsible for accidents or for anything that happens as a result.

Please see below for more information Privacy Practices. 

If You Need to Contact Your Therapist

Your therapist cannot promise to be available at all times. Phone calls cannot be taken while with clients. You can always leave a message on the office voicemail or on your therapist’s voicemail.  Voicemails are available 24 hours a day. Your therapist will return your call as soon as possible. Please be aware that while you may communicate with your therapist by email, we cannot guarantee the confidentiality of email communication.

Your therapist will discuss his/her policy for emergencies or crises. If you have a behavioral or emotional crisis and cannot reach your therapist immediately by telephone, you or your family members should seek assessment and treatment at the nearest hospital emergency room.

If Your Therapist Needs to Contact Someone about You

If there is an emergency during our work together, or your personal safety becomes a concern, your therapist is required by law and by the rules of our professions to contact someone close to you—perhaps a relative, spouse, or close friend. We are also required to contact this person, or the authorities, if we become concerned about your harming someone else. 

  Other Points

If you ever become involved in a divorce or custody dispute, we want you to understand and agree that we will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on two reasons: (1) Your therapist’s statements will be seen as biased in your favor because we have a therapy relationship; and (2) the testimony might affect our therapy relationship, and we must put this relationship first.

Doing follow-up and outcome research is always educational. As professional therapists, we naturally want to know more about how therapy helps people. To understand therapy better, we must collect information about clients before, during, and after therapy. Therefore, we are asking you to help us by filling out some questionnaires about different parts of your life-relationships, changes, concerns, attitudes, and other areas. We ask your permission to take what you wrote on these questionnaires and what we have in our records and use it in research or teaching that we may do in the future. If we ever use the information from your questionnaire, it will always be included with information from many others. Also, your identity will be made completely anonymous. Your name will never be mentioned, and all personal information will be disguised and changed. After the research, teaching, or publishing project is completed all the data used will be destroyed.

If, as part of our therapy, you create and provide to us records, notes, artworks, or any other documents or materials, we will return the originals to you at your written request but will retain copies.

Electronic Records Disclosure

We keep and store records for each client in a record-keeping system produced and maintained by My Clients Plus and Jituzu. This system is “cloud-based,” meaning the records are stored on servers which are connected to the Internet. Here are the ways in which the security of these records is maintained:

• We have entered into a HIPAA Business Associate Agreement with My Clients Plus and Jituzu. Because of this agreement, My Clients Plus and Jituzu are obligated by federal law to protect these records from unauthorized use or disclosure.
• The computers on which these records are stored are kept in secure data centers, where various physical security measures are used to maintain the protection of the computers from physical access by unauthorized persons.
• My Clients Plus and Jituzu employ various technical security measures to maintain the protection of these records from unauthorized use or disclosure.
• We have our own security measures for protecting the devices that we use to access these records:

o   On computers, we employ firewalls, antivirus software, passwords, and disk encryption to protect the computer from unauthorized access and thus to protect the records from unauthorized access.

o   With mobile devices, we use passwords to maintain the security of the device and prevent unauthorized persons from using it to access our records.

 Here are things to keep in mind about our record-keeping system:

• While our record-keeping company and we both use security measures to protect these records, their security cannot be guaranteed.
• Some workforce members at My Clients Plus and Jituzu, such as engineers or administrators, may have the ability to access these records for the purpose of maintaining the system itself. As a HIPAA Business Associate, My Clients Plus and Jituzu  are obligated by law to train their staff on the proper maintenance of confidential records and to prevent misuse or unauthorized disclosure of these records. This protection cannot be guaranteed, however.
• Our record-keeping company keeps a log of our transactions with the system for various purposes, including maintaining the integrity of the records and allowing for security audits. 

 Statement of Principles and Complaint Procedures

It is our intention to fully abide by all the rules of our respective professional organizations and by those of our state license.

Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with your therapist at once. Our work together will be slower and harder if your concerns are not worked out. We will make every effort to hear any complaints you have and to seek solutions to them. If you feel that we, or any other therapist, has treated you unfairly or has even broken a professional rule, please tell your therapist. You can also contact the state or local psychological or counseling association and speak to the chairperson of the ethics committee. He or she can help clarify your concerns or tell you how to file a complaint. You may also contact the state board of psychologist examiners [note that this name differs across states], the organization that licenses those of us in the independent practice of psychology.

In our practice as therapists, we do not discriminate against clients because of any of these factors: age, sex, marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is our personal commitment, as well as being required by federal, state, and local laws and regulations. We will always take steps to advance and support the values of equal opportunity, human dignity, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to our attention immediately. 

 Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. If you have any questions our Privacy Officers will be happy to help you. Their name and address are at the end of this Notice. Please review it carefully.

A. Introduction

This notice will tell you about how we handle information about you. It tells how we use this information here in this office, how we share it with other professionals and organizations, and how you can see it. We want you to know all of this so that you can make the best decisions for yourself and your family. We are also required to tell you about this because of the privacy regulations of a federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Because this law and the laws of this state are very complicated and we don't want to make you read a lot that may not apply to you, we have simplified some parts. If you have any questions or want to know more about anything in this Notice, please ask our Privacy Officer for more explanation or more details. 

B. What we mean by your medical information

Each time you visit us or any doctor's office, hospital, clinic, or any other healthcare provider information is collected about you and your physical and mental health. It may be information about your past, present or future health or conditions, or the treatment or other services you got from us or from others, or about payment for healthcare. The information we collect from you is called, in the law, PHI which stands for Protected Health Information. This information goes into your medical or healthcare record or file at the office. In this office this PHI is likely to include these kinds of information:

•  Your history. As a child, in school and at work, and marital and personal history.
•  Reasons you came for treatment. Your problems, complaints, symptoms, needs, goals.
•  Diagnoses. Diagnoses are the medical terms for your problems or symptoms.
•  A treatment plan. These are the treatments and other services which we think will best help you.
• Progress notes. Each time you come in we write down some things about how you are doing, what we observe about you, and what you tell us.
•  Records we get from others who treated you or evaluated you.
•  Psychological test scores, school records, etc.
•  Information about medications you took or are taking.
•  Legal matters
•  Billing and insurance information

There may be other kinds of information that go into your healthcare record here.

We use this information for many purposes. For example, we may use it:

1. To plan your care and treatment.

2. To decide how well our treatments are working for you.

3. When we talk with other healthcare professionals who are also treating you such

     as your family doctor or the professional who referred you to us.

4. To show that you actually received the services from us which we billed to you or

to your health insurance company.

5. For teaching and training other healthcare professionals.

6. For medical or psychological research.

7. For public health officials trying to improve health care in this country.

8. To improve the way we do our job by measuring the results of our work.

When you understand what is in your record and what it is used for you can make better decisions about whom, when, and why others should have this information. Although your health record is the physical property of the healthcare practitioner or facility that collected it, the information belongs to you. You can inspect, read, or review it. In some very unusual situations, you cannot see all of what is in your records. If you find anything in your records that you think is incorrect or something important is missing you can ask us to amend (add information to) your records although in some rare situations we don't have to agree to do that. 

c. Privacy and the laws

The HIPAA law requires us to keep your PHI private and to give you this notice of our legal duties and our privacy practices which is called the Notice of Privacy Practices or NPP. We will obey the rules of this notice as long as it is in effect but if we change it, the rules of the new NPP will apply to all the PHI we keep. If we change the NPP we will post the new Notice in our office where everyone can see. You or anyone else can also get a copy from our Privacy Officers at any time and it will be posted on our website at www.MalecHerrinandKrause.com. 

D. How your protected health information can be used and shared

When your information is read by your therapist or others in this office that is called, in the law, use. If the information is shared with or sent to others outside this office, that is called, in the law, disclosure. Except in some special circumstances, when we use your PHI here or disclose it to others we share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI , how it is used and to have a say in how it is disclosed and so we will tell you more about what we do with your information. We use and disclose PHI for several reasons. Mainly, we will use and disclose (share) it for routine purposes and we will explain more about these below. For other uses we must tell you about them and have a written Authorization from unless the law lets or requires us to make the use or disclosure without your authorization. However, the law also says that we are allowed to make some uses and disclosures without your consent or authorization. 

Uses and disclosures of PHI in healthcare with your consent

After you have read this Notice you will be asked to sign a separate Consent form to allow us to use and share your PHI. In almost all cases we intend to use your PHI here or share your PHI with other people or organizations to provide treatment to you, arrange for payment for our services, or some other business functions called health care operations. Together these routine purposes are called TPO and the Consent form allows us to use and disclose your PHI for TPO. Re-read that last sentence until it is clear because it is very important. 

For treatment, payment, or health care operations.

We need information about you and your condition to provide care to you. You have to agree to let us collect the information and to use it and share it as necessary to care for you properly. Therefore, you must sign the Consent form before we begin to treat you because if you do not agree and consent we cannot treat you. When you come to see us, several people in our office may collect information about you and all of it may go into your healthcare records here. Generally, we may use or disclose your PHI for three purposes: treatment, obtaining payment, and what are called healthcare operations. Let's see what these are about.

For treatment

We use your medical information to provide you with psychological treatment or services. These might include individual, family, or group therapy, psychological, educational, or vocational testing, treatment planning, or measuring the effects of our services. We may share or disclose your PHI to others who provide treatment to you. We are likely to share your information with your personal physician. If you are being treated by a team, we can share some of your PHI with them so that the services you receive will be coordinated. They will also enter their findings, the actions they took, and their plans into your record and so we all can decide what treatments work best for you and make up a Treatment Plan. We may refer you to other professionals or consultants for services we cannot offer such as special testing or treatments. When we do this we need to tell them some things about you and your conditions. We will get back their findings and opinions and those will go into your records here. If you receive treatment in the future from other professionals we can also share your PHI with them. These are some examples so that you can see how we use and disclose your PHI for treatment.

For payment

We may use your information to bill you, your insurance, or others to be paid for the treatment we provide to you. We may contact your insurance company to check on exactly what your insurance covers. We may have to tell them about your diagnoses,

what treatments you have received, and what we expect as we treat you. We will need to tell them about when we met, your progress, and other similar things.

For health care operations

There are some other ways we may use or disclose your PHI which are called health care operations. For example, we may use your PHI to see where we can make improvements in the care and services we provide. We may be required to supply some information to some government health agencies so they can study disorders and treatment and make plans for services that are needed. If we do, your name and identity will be removed from what we send. 

Other uses in healthcare

Appointment Reminders. We may use and disclose medical information to reschedule or remind you of appointments for treatment or other care. If you want us to call or write to you only at your home or at your work or prefer some other way to reach you, we usually can arrange that. Just tell us.

Treatment Alternatives. We may use and disclose your PHI to tell you about or recommend possible treatments or alternatives that may be of interest to you.

Other Benefits and Services. We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.

Research. We may use or share your information to do research to improve treatments. For example, comparing two treatments for the same disorder to see which works better or faster or costs less. In all cases your name, address and other information that reveals who you are will be removed from the information given to researchers. If they need to know who you are we will discuss the research project with you and you will have to sign a special Authorization form before any information is shared.

Business Associates. There are some jobs we hire other businesses to do for us. They are called our Business Associates in the law. Examples include a copy service we use to make copies of your health record and a billing service who figures out, prints, and mails our bills. These business associates need to receive some of your PHI to do their jobs properly. To protect your privacy, they have agreed in their contract with us to safeguard your information. 

2. Uses and disclosures requiring your Authorization

If we want to use your information for any purpose besides the TPO or those we described above we need your permission on an Authorization form. We don't expect to need this very often. If you do authorize us to use or disclose your PHI, you can revoke (cancel) that permission, in writing, at any time. After that time we will not use or disclose your information for the purposes that we agreed to. Of course, we cannot take back any information we had already disclosed with your permission or that we had used in our office. 

3. Uses and disclosures of PHI from mental health records Not requiring Consent or Authorization

The law lets us use and disclose some of your PHI without your consent or authorization in some cases.

When required by law

There are some federal, state, or local laws which require us to disclose PHI. We have to report suspected child abuse.

If you are involved in a lawsuit or legal proceeding and we receive a subpoena, discovery request, or other lawful process we may have to release some of your PHI. We will only do so after trying to tell you about the request, consulting your lawyer, or trying to get a court order to protect the information they requested. *

We have to release (disclose) some information to the government agencies which check on us to see that we are obeying the privacy laws.

For Law Enforcement Purposes

We may release medical information if asked to do so by a law enforcement official to investigate a crime or criminal.

For public health activities

We might disclose some of your PHI to agencies which investigate diseases or injuries. For certain Insurance Company Requests You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as

treatment plans or summaries, or copies of your entire clinical record. By signing this Agreement, you agree that I can provide requested information to your carrier.

For specific government functions

We may disclose PHI of military personnel and veterans to government benefit programs relating to eligibility and enrollment, to Workers' Compensation programs, to correctional facilities if you are an inmate, and for national security reasons.

To Prevent a Serious Threat to Health or Safety If we come to believe that there is a serious threat to your health or safety or that of another person or the public we can disclose some of your PHI. We will only do this to persons who can prevent the danger. Psychologists are state mandated to report driving impairments. 

4. Uses and disclosures requiring you to have an opportunity to object

We can share some information about you with your family or close others. We will only share information with those involved in your care and anyone else you choose such as close friends or clergy. We will ask you about who you want us to tell what information about your condition or treatment. You can tell us what you want and we will honor your wishes as long as it is not against the law.

If it is an emergency - so we cannot ask if you disagree - we can share information if we believe that it is what you would have wanted and if we believe it will help you if we do share it. If we do share information, in an emergency, we will tell you as soon as we can. If you don't approve we will stop, as long as it is not against the law. 

5. An accounting of disclosures When we disclose your PHI we keep some records of whom we sent it to, when we sent it, and what we sent. You can get an accounting (a list) of many of these disclosures.

E. Your rights regarding your health information

1. You can ask us to communicate with you about your health and related issues in a particular way or at a certain place which is more private for you. For example, you can ask us to call you at home, and not at work to schedule or cancel an appointment. We will try our best to do as you ask.

2. You have the right to ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends.

3. You have the right to look at the health information we have about you such as your medical and billing records.

4. If you believe the information in your records is incorrect or missing important information, you can ask us to make some kinds of changes (called amending) to your health information. You have to make this request in writing and send it to our Privacy Officers. You must tell us the reasons you want to make the changes.

5. You have the right to a copy of this notice. If we change this NPP we will post the new version in our waiting area and you can always get a copy of the NPP from the Privacy Officers. 6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our Privacy Officer and with the Secretary of the Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care we provide to you in anyway. 

F. If you have questions or problems

If you need more information or have questions about the privacy practices described above please speak to the Privacy Officer whose names and telephone number are listed below. If you have a problem with how your PHI has been handled or if you believe your privacy rights have been violated, contact one of the Privacy Officer. You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services. We promise that we will not in any way limit your care here or take any action against you if you complain. If you have any questions regarding this notice or our health information privacy policies, please contact our Privacy Officer who is Elaine Malec, PhD can be reached by phone at 724-252-4637 or by e-mail at [email protected].

You may have other rights which are granted to you by the state laws; these may be the same or different from the rights described above. We would be happy to discuss these situations with you now or as they arise. 

Our Agreement

I, the client (or his or her parent or guardian), understand I have the right not to sign the acknowledgement form. My signature on the acknowledgement form indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them.

I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy with you.

I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective.

I have read, or have had read to me, the issues and points in this brochure. I have discussed those points I did not understand, and have had my questions, if any, fully answered. I agree to act according to the points covered in this brochure. I hereby agree to enter into therapy with this therapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability.

If, after reading this and discussing it with your therapist, you are concerned with issues surrounding Managed Care Insurance, you may have the choice of paying directly to your therapist and not using your health insurance. This will create no record outside of his or her files. This possibility may depend on your therapist’s contract with the MCO.

After you read this information we can discuss, in person, how these issues apply to your own situation. Write down any questions you think of, and we can discuss them at our next meeting.

For more information please contact us at 724-252-4637 or email us at [email protected]. 

 What You Should Know about Managed Care and Your Treatment

Your health insurance may pay part of the costs of your treatment, but the benefits cannot be paid until a managed care organization (MCO) authorizes this (says they can be paid). The MCO has been selected by your employer, not by you or us. The MCO sets some limits on us, and you need to know what these are before we go further.

 Confidentiality

If you use your health insurance to help pay for psychotherapy, you must allow us to tell the MCO about your problem (give a psychiatric diagnosis). You must also permit us to tell the MCO about the treatment we are recommending, about your progress during treatment, and about how you are doing in many areas of your life (functions at work, in your family, and in activities of daily living). We are not paid separately for collecting, organizing, or submitting this information, and we cannot bill you for these services. All of this information will become part of the MCO’s records, and it will be included in your permanent medical record at the Medical Information Bureau, a national data bank. The information will be examined when you apply for life or health insurance, and it may be considered when you apply for employment, credit or loans, a security clearance, or other things in the future. You will have to indicate that you were treated for a psychological condition and release this information, or you may not get the insurance, job, loan, or clearance.

All insurance carriers claim to keep the information they receive confidential, and there are federal laws about its release. The laws and ethics that apply to us are much stricter than the rules that apply at present to MCOs. There have been reports in the media about many significant and damaging breaches of confidentiality by MCOs. If you are concerned about who might see your records now or in the future, we should discuss this issue more fully before we start treatment and before we send the MCO any information. You should evaluate your situation carefully in regard to confidentiality. For some people and some problems, the privacy of their communications to their therapist is absolutely essential to their work on their difficulties. For others, their problems are not ones that raise much concern over confidentiality.

 Treatment

The MCO will review the information we send it and then decide how much treatment we can provide to you. The MCO can refuse to pay for any of your treatment, or for any treatment by your therapist. Or it may pay only a very small part of the treatment’s cost, and it can prevent your therapist from charging you directly for treatment we agree to. Finally, it can set limits on the kinds of treatments your therapist can provide to you. These limited treatments may not be the most appropriate for you or in your best interest. The MCO will approve treatment aimed at improving the specific symptoms (behaviors, feelings) that brought you into therapy, but it may not approve any further treatment. The MCO will almost always require you to see a psychiatrist for medication evaluations (and prescriptions), whether you or your therapist  think this is appropriate.

When it does authorize our treatment, the MCO is likely to limit the number of times we can meet. Your insurance policy probably has a maximum number of appointments allowed for outpatient psychotherapy (usually per year, though there may be a lifetime limit as well), but the MCO does not have to let you use all of those. It may not agree to more sessions, even if we believe those are needed to fully relieve your problems, or if we believe that undertreating your problems may prolong your distress or lead to relapses (worsening or backsliding).

If the MCO denies payment before either of us is satisfied about your progress, we may also need to consider other treatment choices, and they may not be the ones we would prefer. Your therapist  can appeal the MCO’s decisions on payment and number of sessions, but he or she can only do so within the MCO itself. Your therapist  cannot appeal to other professionals, to your employer, or through the courts. This state does not have laws regulating MCOs —that is, laws about the skills or qualifications of their staff members, about access to medical and psychological records by employers and others, or about the appeals process.

You should know that your therapist’s contract or your employer’s contract with a particular MCO prevent us from taking legal actions against the MCO if things go badly because of its decision. Your therapist’s  contract may prevent him or her from discussing with you treatment options for which the MCO will not pay. We will discuss with you any efforts the MCO makes to get us to limit your care in any way.

The particular MCO in charge of your mental health benefits can change during the course of your treatment. If this happens, we may have to go through the whole treatment authorization process again. It is also possible that the benefits or coverage for your treatment may change during the course of our therapy, and so your part of costs for treatment may change.

Lastly, even if we send all the forms and information to the MCO on time, there may be long delays before any decisions are made. This creates stressful uncertainty and may alter our earlier assumptions about the costs and nature of your treatment.

 Our Agreement About Managed Care 

If, after reading this and discussing it with your therapist, you are concerned with these issues, you may have the choice of paying directly to your therapist and not using your health insurance. This will create no record outside of his or her files. This possibility may depend on your therapist’s contract with the MCO.

After you read this information we can discuss, in person, how these issues apply to your own situation.  Write down any questions you think of, and we can discuss them at our next meeting.

For more information please contact us at 724-252-4627 or email us at [email protected].