PRACTITIONER-CLIENT SERVICES AGREEMENT
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.
COACHING/PSYCHOTHERAPY SERVICES
Coaching and Psychotherapy are not easily described in general statements. They vary depending on the personalities of the coach/therapist and client, and the particular presenting problems. There are many different methods I may use to deal with the issues. Seeing a coach or psychotherapist is not like going to a medical doctor. Instead, it calls for an active effort on your part. In order for the work to be most successful, you will have to process what we talk about both during our sessions and at home.
Coaching and psychotherapy can have risks as well as benefits. Our discussions may involve bringing up unpleasant aspects of your life, which can possibly make you feel uncomfortable. Negative emotions such as: sadness, guilt, anger, frustration, loneliness, and helplessness may arise. On the other hand, coaching and psychotherapy have many benefits. They often lead to personal empowerment, breakthroughs, better relationships, solutions to specific problems, an increase in happiness, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
Our first session will involve an evaluation of your goals and needs. By the end of that time, I will be able to offer you some impressions of what our work will include if you decide to continue working with me. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Coaching and therapy involve a significant commitment of time, money, and energy, so you should be careful about the practitioner you select. If you have questions about my process, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another professional.
PROFESSIONAL FEES
My standard fees are available on my website. Sessions are either 50 minutes or 75-minutes in length. However, I require a commitment of at least 6 sessions which can be purchased in packages of 3 or 6.
In addition to one-on-one appointments, I charge this amount for other professional services you may need. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me.
CONTACTING ME
Due to my work schedule, I may not be immediately available by telephone. While I am usually available during working hours, my phone calls are always automatically routed to my confidential voice-mailbox. I retrieve and return all messages as soon as possible. At night, and on weekends and holidays, there may occasionally be a somewhat longer time period before I can get back to you, since I may be engaged in an activity that makes returning your call difficult to do right away. If you are difficult to reach, please inform me of some times when you will be available to reach. If you are for some reason unable to reach me and feel that you can’t wait for me to return your call and it is an emergency, contact your family physician or the nearest emergency room. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient/client and a therapist/coach. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my client. The other professionals are also legally bound to keep the information confidential. If you don’t object, I will not tell you about these consultations unless I feel that it is important to our work together.
You should be aware that I interact with other mental health professionals. In some cases, I need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All billing staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.
Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations where I am permitted or required to disclose information without either your consent or Authorization:
If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order, or if I receive a subpoena of which you have been properly notified and you have failed to inform me that you oppose the subpoena. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
· If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, I may be required to provide it for them.
· If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself.
· If a client files a worker’s compensation claim, and I am providing necessary treatment related to that claim, I must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient’s employer, the insurance carrier or an authorized qualified rehabilitation provider.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client’s treatment. These situations are unusual in my practice.
§ If I know, or have reason to suspect, that a child under 18 is abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child’s welfare, the law requires that I file a report with the Department of Social and Health Services or the Department of Children. Youth and Families. Once such a report is filed, I may be required to provide additional information.
§ If I know or have reasonable cause to suspect that a vulnerable adult has been or is being abused, neglected, or exploited, the law requires that I file a report with the abuse hotline. Once such a report is filed, I may be required to provide additional information.
§ If I believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, I may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or seeking hospitalization of the client.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking coaching/therapy, a description of the ways in which your problem impacts your life, your goals and objective, possible diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that I receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier.
Except in unusual circumstances that disclosure would physically endanger you and/or others, or makes reference to another person (other than a health care provider) and I believe that access is reasonably likely to cause substantial harm to such other person, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents. In some circumstances, I will charge a copying fee of $1.00 per page (and for certain other expenses). I may withhold copies of your records until payment of the copying fees has been made. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Records, you have a right of review, which I will discuss with you upon request.
In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. They also include information from others provided to me confidentially. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.
CLIENT RIGHTS
HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.
This is a condensed version of the Health Insurance Portability and Accountability Act (H.I.P.A.A.) contract for client confidentiality. HIPAA requires that we inform you of your rights and privacy regarding your health information.
· You have a right to adequate notice of use and disclosure of your health information.
· You have a right to revoke an authorization to disclose your health information.
· You have a right to access your protected health information (PHI) in the form and format you request.
· You have a right to read the original records and/or obtain a readable copy at a time and place that is convenient for you.
· You may be denied access, and if so you have the right to appeal the decision.
· You have a right to request an amendment to health information for such things as accuracy and completeness of PHI that is generated by and filed in this provider's record.
· This provider has the right to deny your request for amending your record.
· HIPAA requires this provider to collect more detailed information when (a) you request access and (b) if you are denied your request to amend your PHI.
· HIPAA requires that a licensed health professional review any denials this provider makes.
· Your requests for access or amendment must be made in writing. Please keep a copy.
· If you are denied a request to amend your record, you have a right to appeal by writing a letter. Please keep a copy.
· You have a right to request restrictions on disclosing protected health information.
· You have a right to request an accounting of disclosures made for purposes that are not treatment, payment, or this provider's operations.
If you have any questions regarding the Notice or my privacy rights, you can contact Shakti Sutriasa at (206) 486-4338.
COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with Shakti Sutriasa at Decide Differently, LLC or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.