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Our meeting includes an initial assessment
regarding whether or not I can offer you a service
which might be helpful to you, and whether or not
you feel comfortable working with me. You should evaluate this information
along with your own assessment about whether you
feel comfortable working with me.
Psychological services may involve a commitment of
time, money, and energy, so you should be very
careful about the provider you select. If you have
questions about my procedures, we should discuss
them whenever they arise. If your doubts persist, I
will be happy to help you to secure an appropriate
consultation with another professional. You can seek
a second opinion from another professional or
terminate services at any time.
MEETINGS
My Office
Manager schedules all Evaluation appointments.
PROFESSIONAL RECORDS
Both the law and the standards of my profession
require that I keep an appropriate treatment record
or "file" which is my professional property. You are
entitled to receive a copy of the record, but if you
wish I can prepare an appropriate summary. Because
these are professional records, they can be
misinterpreted; if you wish
to see your records, I recommend that you review
them in my presence so that we can discuss what they
contain. I am sometimes willing to conduct such a
meeting without charge. Clients will be charged an
appropriate fee for any preparation time which is
required to comply with an information request.
CONFIDENTIALITY
An important understanding for individuals, couples,
and families seeking psychological services is the
nature of confidentiality in treatment. While all
matters related to your psychological services are held
in the strictest professional confidence, there are
some understandings and legal aspects to
confidentiality that I would like you to know.
The
Health Insurance Portability and Accountability Act
(HIPAA) of 1996 (P.L.104-191) forms also tell how private data may be used.
Clients have a clinical record or "file" which is
the property of my clinical practice. Routine
release of any information about or from this record
requires a dated and signed authorization by the client(s) which specifically designates what may be
released and to whom. A phone call request to
release information is not sufficient.
Parents or guardians may obtain information
about their legal minor (younger than 18) for whom
they are responsible; if you are under eighteen years of age,
please be aware that the law may provide your
parents with the right to examine your treatment
records.
Please be aware that I have an ethical obligation to
balance the interests of all clients. If you inform
me of a situation that, in my opinion, is blatantly
harmful, unfair, or unethical, or if, in my opinion,
psychological services cannot profitably proceed unless something
you tell me is shared with your person(s), I may at
my discretion give you the choice of correcting the
situation when that is feasible, informing the other(s) of the situation, having me tell the
other(s), or terminating treatment.
Situations which may permit or require release of
private information are:
1) Ordinarily, information is only released
when you authorize it in writing such as to exchange
information with another provider, or health
insurance company. Please be
aware that if you have third-party reimbursement
(health insurance or HMO) and file a claim with
authorization for release, that your insurance
company may request or require detailed information,
and in some cases a copy of your file. If the
request is more than routine practice, I will call
you for you to decide. Please realize that I do all
I professionally can to protect and honor your
confidentiality.
2) By Wisconsin State Statute, helping
professionals are required to immediately report
every case of specific physical and/or sexual abuse
of children (minors) and "vulnerable adults"
(mentally limited, severely ill, legally
"incompetent", etc.) to the appropriate legal
authority (child protection department, police).
In such cases, confidentiality between the patient
/client and therapist
must
be broken.
3) In cases where there is imminent danger to
an individual, such as severe risk of harming one's
self (suicidal) or danger of harming another
(homicidal), the professional is required to act to
protect. In the case where the client may
disagree, it must be the professional's clinical
judgment to decide when confidentiality must be
broken in the interest of protection of the client
or others from harm. If I believe that a client is
threatening serious bodily harm to another, I may be
required to take protective actions which may
include notifying the potential victim, notifying
the police, or seeking appropriate hospitalization.
If a client threatens to harm him/herself, I may be
required to seek hospitalization for the client, or
to contact family members or others who can help
provide protection. These situations have rarely
arisen in my practice. Should such a situation
occur, I will make every effort to fully discuss it
with you before taking any action.
4) In cases where there is a legal subpoena
requiring the release of records, information must
be disclosed. This is rare, and a subpoena is
not easily obtained. In many judicial proceedings,
you have the right to prevent me from providing any
information about my psychological services to you,
or in some cases, you may have the option to
authorize me to offer a summary of your record.
However, in some circumstances a judge may require my
testimony if he/she determines that resolution of
the issues before him/her demands it. It is
important to remember that providers have knowledge
which may be subpoenaed -- not only the patient
record. Please assume that any and all information
that you share with me can and may be included in
any reports or opinions. When your welfare may
become a point of litigation, your right to
confidentiality may be waived by requirement and
your psychologist can be compelled to release the file,
give a deposition, or testify in court. Also, if
you are seeking an evaluation for legal purposes,
please inform me of this specifically at the
beginning of our work.
COMPLAINT or GRIEVANCE
If, for any reason, you are not satisfied with the
services you are receiving from me, please talk it
over with me to see if we can resolve the problem.
If you believe your rights have been violated, you
may contact the:
Wisconsin Psychology Examining Board
Department of
Regulation & Licensing
Bureau of Health
Service Professions
P.O. Box 8935
Madison, WI
53708-8935
(608) 266-2112
You also have the right to file complaints related
to privacy regulations with the U.S. Department of
Health and Human Services (DHHS)
PROFESSIONAL FEES
Fees for specific services are listed within
the descriptions of each service.
If you have medical insurance, your mental health
coverage may help with clinical services and my
psychological testing/evaluation fee.
My office manager handles all insurance
questions and may be reached at 715.235.0375.
In addition to regular appointments, it is my
practice to charge at the clinical rate on a
prorated basis for other professional services you
may require such as telephone conversations which
last longer than 10 minutes, attendance at meetings
or consultations with other mental health
professionals which you have authorized, preparation
of records or treatment summaries, or the time
required to perform any other service which you may
request of me – services which insurance may not
cover.
When you request and authorize it, copying your
records for release to another professional or
medical service (e.g., underwriting service
evaluating your life insurance application) is also
charged to you at $1.15 per page, and $15.00 per
clerical services.
In unusual circumstances, you may become involved in
litigation which may require my participation. You
will be expected to pay for the professional time
required even if I am compelled to testify by
another party. I charge $190 per hour for legal
report writing, consultation, preparations and
attendance at any legal proceeding (as well as
reimbursement for any related expenses such as
travel time, parking and meals.).
BILLING AND PAYMENTS
You will be expected to pay for all services by
check or cash at the time they are provided; we do
not take credit cards. In the case of an evaluation
the
fee is due at the time of services and you
will be reimbursed whatever amount we may receive from
your insurance company. We will bill your insurance
company, if the insurer has indicated there is
coverage, and request that you be directly
reimbursed for the portion insurance covers,
however, it is likely the insurer will send any
monies to my office and if this occurs, I will issue
my own check to you for that amount. Some insurance
companies require a “Preauthorization” which
typically delays our first appointment by several
weeks.
INSURANCE
In order to set realistic goals and
priorities, for psychological services it is important to evaluate what
resources are available to pay for services. If you
have a health benefits policy, it will usually
provide some coverage for mental health treatment
and this
MAY
cover a portion of my evaluation services, I do not
bill insurance companies for psychological services,
with the exception of psychological
evaluations. Non evaluation services are offered at a reduced rate
due to fewer “paperwork” charges.
Please remember that my services are provided for
and charged to you, not to your insurance company
and
you, and not your insurance company, are responsible
for full payment of the fee.
Carefully read the section in your insurance
coverage booklet which describes mental health
services depending on the type of coverage you may
have.
If you submit a claim to your insurance company
yourself you should keep your session receipt to
attach to your claim
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