NEW CLIENT TREATMENT AGREEMENT AND INFORMATION

Welcome to my therapy practice. I look forward to working with you. This form contains information about my services and policies. Please take a few minutes to review this information, and if you have any questions, I will be happy to discuss them with you in our first session. You may choose to initial and sign in advance, or wait until we have discussed its contents.

Should you ever have any questions about the nature of treatment or anything else about your care at any time, please do not hesitate to ask.

CONFIDENTIALITY 

All information between provider and client (and client's family members, for family sessions) is held strictly confidential unless:

1. The client (or parent/guardian in case of a minor) authorizes release of information with his/her signature

2. The client presents a physical danger to self

3. The client presents a danger to others

4. Child abuse or neglect are suspected

5.   In extremely rare circumstances, files may be subpoenaed by court

In a case of child abuse/neglect, I may be required by law to inform the appropriate authorities so that protective measures can be taken.

I participate in professional consultation as a means to maintaining the highest standards of care and continuing to improve my own delivery of services.

Because of the nature of the internet, confidentiality cannot be assured in un-encrypted e-mail messages, therefore your use of such forms of communication constitutes implied consent for reciprocal use of e-mail.

FINANCIAL TERMS

Health Insurance

There are benefits and risks associated with the use of health insurance to cover psychotherapy. Certainly, insurance companies are seeing the value of psychotherapy, and covering it as a benefit. A primary benefit is the coverage of a significant portion of the fee, leaving a smaller co-pay or deductible. This is usually rendered without complication or difficulty. However, there are some risks involved, which include: 

1) Insurance companies require medical necessity of treatment, which in turn requires a diagnosis and treatment plan related to the treatment of that diagnosis. 

2) Having a diagnosis may then become a "pre-existing condition" and may impact your ability to apply for life insurance policies or other insurance policies if / when your previous medical records are requested. 

3) Using insurance means that there are additional limits to confidentiality. Once insurance is billed for therapy, there are many people within the insurance company who will have access to this billing information, and Laura Martin, LCSW does not have control over the use of that information. Insurance companies may or may not request clinical information during or after the course of your treatment. We can discuss if and how you would want clinical information to be shared if such a request from an insurance company arises, and declining to share this information could result in the insurance company's refusal to pay. Laura Martin, LCSW will communicate only the minimum information necessary to the carrier. 

4) If the number of authorized sessions is used up, your therapist may need to contact the insurance company to discuss your case with a case reviewer, to determine whether additional sessions are warranted. The insurance company's case reviewer decides whether additional sessions will be covered, regardless of whether you or your therapist feels it is appropriate.

I am not on most insurance panels, so any use of insurance would need to be as an out-of-network provider, and would require you to submit a superbill to your insurance for reimbursement.  You are responsible for paying the fee at the time of service. 

I use a bookkeeping service for general financial records, and I may occasionally use a billing and/or bookkeeping service to facilitate collection of fees from insurance companies. I endeavor to utilize as little identifying information as possible but there may be times that basic identifying information might be available to bookkeepers, or in the case of insurance, some information about diagnosis and treatment.

Having insurance does not guarantee payment. You will be responsible for all charges incurred in the event that the insurance company does not pay.

Clients are required to leave authorized credit card information on file. I reserve the right to not accept clients without a current credit card. All outstanding fees due from the patient will be automatically charged to the credit card if not paid within 30 days. All fees not paid by insurance will be charged after 90 days.

You have the legal right to revoke authorization to charge your credit card at any time. However, doing so may result in termination of services. In case of non-payment for services rendered, we may use a collection agency to pursue fees that are left unpaid for more than three months subsequent to the date of provision of services.

Financial Terms - Fee for Service

Appointments are ordinarily 45-50 minutes in duration, and take place weekly as we are starting out, and may settle into a maintenance schedule with appointments every other week or less frequently as needed.  My current fees are $175 for intake, and $150 per regular session, $175 for couples / family sessions.  I offer a sliding scale between $130 and $150 with a limited number of slots for a wider scale.    

By signing this agreement, you agree to the following:  

"I understand it is my responsibility to pay for services provided. I also understand that if an appointment is missed or cancelled with less than 24 hours notice, I will be responsible for paying the full scheduled fee."

I collect payments at the end of each session.  I accept Visa, MasterCard, personal checks or cash. 

If you are involved in litigation, you agree to pay for my time to be involved with your case.  This includes, but is not limited to time spent traveling to and from the courthouse, consulting with attorneys, attending depositions, reviewing materials in preparation for testimony, testimony, and waiting to be called to testify.

RELEASE OF INFORMATION

By signing this form, you authorize as follows:

"I authorize the release of information regarding my care to my health plan and / or to appropriate entities for consultation regarding the payment of claims, certifications and case management decisions, and other purposes related to the administration of benefits for my plan or my account."

MINORS IN TREATMENT

For parents of minors in treatment, please be aware that you will be active participants in your child's treatment, and I will expect you to attend at least part of each of your child's sessions for family work. In addition, non-custodial parents have equal rights to give consent to treatment and to access the records of minor children.

If you are a minor in treatment, I will exercise discretion and respect in terms of the information shared with your parent(s) / guardian(s) regarding your treatment process, and we will discuss what that information is or might include. Secrets cannot be kept from others participating in your treatment, so for clients under the age of 18, absolute confidentiality cannot be guaranteed from your parent(s) or guardian(s).

CANCELLED AND MISSED APPOINTMENTS

A scheduled appointment means that time is reserved only for you. Please cancel appointments as soon as possible and no later than 24 hours before the scheduled appointment. If an appointment is missed or cancelled with less than 24 hour notice, you will be billed for the full scheduled fee. In the event of illness, cancellations are allowed before 8:00 AM the day of the appointment. In the case of a verifiable emergency, you will be exempt from paying. Health plans usually do not cover payment for missed appointments; therefore, you will be responsible for the fee in such a case.

TELEPHONE CALLS

At times, clients may require or desire additional services in the form of telephone contact between sessions. I charge a fee for telephone consultations over 10 minutes in length, according to the length of the call. Please be aware of this policy, and make an informed decision regarding whether you wish to receive this form of treatment. As insurance generally does not pay for telephone contact, such sessions will be offered on a fee-for-service basis, under which you will be responsible for the whole fee.


EMERGENCY PROCEDURES

If you need to contact me under normal circumstances, please leave a message according to the instructions on my voicemail, and your call will be returned as soon as I am able to do so during business hours. I endeavor to return calls within 24 hours or one business day. If an emergency situation arises that presents a significant and imminent risk of physical endangerment to any individual, please call 911, or go to the nearest hospital Emergency Room to receive immediate care. If you are experiencing a non-life threatening mental health crisis outside of regular business hours, or are in need of emotional support after hours, you may call the Multnomah County Crisis Line at 503-988-4888.

SOCIAL MEDIA / TEXT MESSAGING

I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

Please do not use messaging on Social Networking sites such as Twitter, Facebook, or LinkedIn to contact me. These sites are not secure and I may not read these messages in a timely fashion. Do not use Wall postings, @replies, or other means of engaging with me in public online if we have an already established client/therapist relationship. Engaging with me this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and will need to be documented and archived in your chart. 

Please do not use mobile phone text messaging, as I may not see these messages immediately.  

If you need to contact me between sessions, the best way to do so is by phone, or by direct email at Laura@LauraMartinLCSW.com for quick, administrative issues such as changing appointment times. See the email section below for more information regarding email interactions.

EMAIL

I prefer using email only to arrange or modify appointments. Please do not email me content related to your therapy sessions, as email is not completely secure or confidential. If you choose to communicate with me by email, be aware that all emails are retained in the logs of your and my Internet service providers. While it is unlikely that someone will be looking at these logs, they are, in theory, available to be read by the system administrator(s) of the Internet service provider. You should also know that any emails I receive from you and any responses that I send to you become a part of your legal record.  I encourage you to utilize the secure client portal for any clinical communication.  

TREATMENT

Your active involvement in therapy, including regular attendance of scheduled sessions, willingness to try new behaviors in and out of session, and willingness to discuss difficult issues, is integral to therapeutic success.

Often therapy begins with some focus on the areas of difficulty that are bringing you here, and your goals for how you would like things to be. I look at these areas holistically and within the context of your life, so in the initial sessions of therapy, I will want to learn about your family history, significant relationships, any traumas, medications, emotional and behavioral patterns, etc. While issues of past and future are important to some degree, our focus will return to the power and wisdom of the present moment. In therapy we will practice increasing moment-to-moment awareness of thoughts, emotions, sensations, and behaviors. We will also look at how changes in these areas may be conducive to improved health.

If at any point you feel our work together is stuck, not addressing areas you would like, or that you are not clear about what the process is, please let me know, and we can work together to return to a process that feels effective and clear.

You have the right to stop treatment at any time. Ideally it will be informed by a sense of accomplishing the goals you came in with. At whatever point you decide to terminate, it can be helpful to schedule a closing session. This is an opportunity to acknowledge the growth and changes you have experienced, to identify your current growth areas, and how you will continue to meet them.

You may want or need a referral to a different therapist, or a different kind of therapy. I am happy to provide you with referrals or recommendations for other therapists, or alternative treatments, which can include no treatment.

CONSENT FOR TREATMENT

By signing this form, you are giving me consent to treat you and/or your family member as follows:

"I authorize and request that my treating provider carry out mental health examinations, treatments, and/or diagnostic procedures, which now or during the course of my care are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and uncomfortable."

"I understand and agree to all of the above information and policies."

Laura Martin, LCSW
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.
PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.

As a social worker licensed in this state and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.

Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.

Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.

Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.

Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.

Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Research. PHI may only be disclosed after a special approval process or with your authorization.

Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.

Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.

With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.

YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer:  Laura Martin, LCSW 4784 N Lombard Street Suite B161 Portland, OR 97203.

Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a "designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.

Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Laura Martin, LCSW 4784 N Lombard Street Suite B161 Portland, OR 97203 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.

The effective date of this Notice is September 2013.

Receipt and Acknowledgment of Notice

I hereby acknowledge that I have received and have been given an opportunity to read a copy of Laura Martin LCSW's Notice of Privacy Practices. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact Laura Martin, LCSW 4784 N Lombard Street Suite B161 Portland, OR 97203.