New Client Forms for Luke Evans

Client Information

West County Psychological Associates will provide you with an invoice after each visit which you may mail to your insurance company if you are planning to file.

Informed Consent for Testing Services

Welcome to our practice. This document contains important information about our professional services and business policies. Please read it carefully. When you sign this document, it will represent an agreement with West County Psychological Associates (WCPA).

Testing Services

Psychoeducational and psychological testing are collaborative processes between you and a professional clinician to share relevant background information, identify areas of concern, complete formalized testing measures, and discuss testing results and appropriate recommendations. For testing to be most effective, it is important that you take an active role in the process. Testing is not an identical process for everyone. There are many different methods your clinician may use to investigate the problems that you identify together. The type and extent of services that you receive will be determined following an initial interview. If you have any questions about testing procedures, you are always free to discuss them with your testing clinician.

Benefits and Risks

Testing has benefits and risks. Since all mental health services often involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, or anger. Benefits may include greater self-understanding and ability to make appropriate life and/or school decisions, among others. Each person’s experience and outcomes are unique to their own circumstances.

Confidentiality and Professional Records

The privacy of all records and communications between a client and a mental health clinician is protected by law. In general, we can only release your information, including testing reports, with your written permission. There are a few exceptions to this general rule, including:

• When a valid court order is issued for records and/or testimony on the part of the clinician, the clinician is bound by law to comply with such an order.
• When there is risk of imminent harm to you or to another person, the clinician is ethically bound to take necessary steps to prevent such harm. This notification may include notifying an intended target of violence, notifying the police, informing a family member about the situation, or seeking appropriate hospitalization.
• When there is suspicion that a child or other dependent person has been sexually, physically or mentally abused or neglected, the clinician is legally required to inform the proper authorities.
• Ethical clinicians consult with professional colleagues about their cases, in order to provide clients the best possible services. If your clinician consults with a colleague, your clinician will not share your name or identifying information.

Fees for Additional Services

If you request that your clinician provide non-testing services, such as attending meetings with school officials or other professionals, charges for those services will normally be higher than the usual rate for in-office testing services and are not included in your original testing fees.

If you become involved in legal proceedings that require your testing clinician’s participation, you will be expected to pay for his or her professional time even if called to testify by another party. Because of the difficulty of legal involvement, charges for such services are higher than those for regular testing services.

Testing clinicians, at their discretion, may charge for excessive time spent on phone calls. This includes calls you make to the clinician as well as calls the clinician makes to others at your request, such as to your child’s school or to your attorney.

Contacts and Emergencies

You may contact your clinician through the WCPA office phone number, (314) 275-8599. In case of an emergency, please call 911 or go to your nearest emergency room. Your clinician is not on-call at all times and may be unreachable. You may leave an emergency message on his or her office voicemail, and your clinician will return your emergency call when they are able.

Minors

Clinicians at WCPA regularly include parents in the testing process with their children. Initial interviews and final sessions, during which the written report is presented, will normally be held with adults only. Parents are responsible for deciding whether and how to share the report’s information with their minor child. Your clinician will discuss this with you if you have concerns. WCPA clinicians will notify parents if they believe the minor client is at risk for harm. WCPA clinicians do not see minors under age 18 for psychological testing without parental consent.

In the case of separated or divorced parents, WCPA requires a copy of the legal parenting plan. Unless otherwise stated in the legal parenting plan, both parents must provide signed consent for their minor child to receive testing services and both parents have the right to exchange information with the clinician about the minor child’s testing and results.

Electronic Transmissions

WCPA cannot ensure the confidentiality of any form of communication through electronic media. You are advised that any text, email, or internet-enabled communication between you and your clinician involves greater risk to confidentiality than does traditional in-person communication. WCPA strongly discourages electronic communication between clients and their clinicians.

Termination

At any time, you have the right to seek a second opinion with another qualified mental health professional. You also have the right to terminate the testing process at any time. If you choose to do so, your clinician may offer to provide you with names of other professionals whose services you might prefer. You will remain responsible for paying the fees of any portion of the testing process that was completed.

Informed Consent for Therapy Services

Consent to Treatment

I voluntarily consent to receive, and/or for my minor child(ren) to receive, mental health assessment, care, testing and treatment. I authorize my clinician through WCPA to provide such professional services. I understand and agree that I will participate in the planning of my testing services and that I may stop these services at any time. By signing below, I acknowledge that I have both read and understood the information in West County Psychological Associates’ Informed Consent for Testing Services document and agree to its terms. This consent ends when I notify my clinician that I am terminating services or one year following my last appointment.

In the case of a minor client, the signature of a parent is required.

If parents are divorced or legally separated, the signatures of both parents are required unless otherwise stated in the legal parenting plan.

Notice of Privacy Practices

The privacy of your personal information is important to West County Psychological Associates (WCPA). WCPA will maintain the privacy of your information and will not disclose your information to others unless you tell WCPA to do so, or unless the law authorizes or requires WCPA to do so.

A federal law commonly known as HIPAA requires that WCPA take additional steps to keep you informed about how WCPA may use information that is gathered in order to provide health care services to you. As part of this process, WCPA is required to provide you with the attached Notice of Privacy Practices and to request that you sign the written acknowledgement that you received a copy of the Notice. The Notice describes how WCPA may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding personal information WCPA maintains about you and a brief description of how you may exercise these rights.

If you have any questions about this Notice please contact WCPA’s Director, Dr. Mary Fitzgibbons, at (314) 275-8599.

WCPA is required by applicable federal and state law to maintain the privacy of your health information. It is also required to give you this Notice about privacy practices, legal obligations, and your rights concerning your health information (“Protected Health Information” or “PHI”). It must follow the privacy practices that are described in this Notice (which may be amended from time to time).

For more information about privacy practices, or for additional copies of this Notice, please contact WCPA using the information listed in Section II G of this notice.

I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI)

A. Permissible Uses and Disclosures without Your Written Authorization
WCPA may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. Treatment: WCPA may use and disclose PHI in order to provide treatment to you. For example, WCPA may use PHI to diagnose and provide counseling service to you. We may also disclose your information in order to remind you of appointment times. We may disclose your information to any family members or significant others that you voluntarily decide to bring to and include in a therapy session. We may disclose your PHI, with the exception of identifying information, during professional clinical supervision and/or consultation, in order to ethically provide you the highest quality services.
2. Payment: WCPA may use or disclose PHI so that services you receive are appropriately billed and payment is collected. By way of example, it may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.
3. Health Care Operations: WCPA may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.
4. Required or Permitted by Law: WCPA may use or disclose PHI when it is required or permitted to do so by law. For example, it may disclose PHI to appropriate authorities if it reasonably believes that you or a child are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition it may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law.

B. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you (“Psychotherapy Notes”) will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.
2. Marketing Communications: WCPA will not use your health information for marketing or fundraising communications without your written authorization. You have the right to opt out of any marketing or fundraising communications that you choose not to receive.
3. Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before WCPA can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.

II. YOUR INDIVIDUAL RIGHTS

1. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by WCPA in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, WCPA may deny access to your records. WCPA may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor’s medical record may not be accessible to you, in accordance with state law. You have the right to an electronic communication of any records that WCPA keeps electronically.
2. Right to Alternative Communications. You may request, and WCPA will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
3. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. WCPA is not required to agree to any such restriction you may request. One exception is that, if you self-pay at WCPA, you may request that we not disclose these services to your health insurance company and WCPA is obligated to honor that request.
4. Right to Accounting of Disclosures or Breaches. Upon written request, you may obtain an accounting of disclosures of PHI made by WCPA after October 1, 2013. This right is subject to restrictions and limitations. You also have the right to be notified by WCPA if a privacy breach of your PHI has occurred. If such a breach occurred, you would be notified within a reasonable time.
5. Right to Request Amendment. You have the right to request that WCPA amend your health information. Your request must be in writing, and it must explain why the information should be amended. WCPA may deny your request under certain circumstances.
6. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.
7. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that WCPA has violated your privacy rights, you may contact the Privacy Officer, Director Mary Fitzgibbons, Ph.D., at (314) 275-8599. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. WCPA will not retaliate against you if you file a complaint with the Director or the Privacy Officer.

III. EFFECTIVE DATE AND CHANGES TO THIS NOTICE

1. Effective Date. This Notice is effective on October 1, 2013.
2. Changes to this Notice. WCPA may change the terms of this Notice at any time. If WCPA changes this Notice, it may make the new notice terms effective for all PHI that it maintains, including any information created or received prior to issuing the new notice. If WCPA changes this Notice, it will post the revised notice in the waiting area of the office and on our website. You may also obtain any revised notice by contacting the Privacy Officer.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

If this acknowledgment is signed by a personal representative on behalf of the client, complete the following:

Informed Consent for Telehealth Testing Services

I understand that I have the following rights with respect to telehealth testing services:

1. I have the right to withhold or withdraw consent at any time without affecting my right to future testing, care or treatment.
2. The laws that protect the confidentiality of my medical information also apply to telehealth services. As such, I understand that the information disclosed by me during the course of telehealth testing services is generally confidential. However, there are limits and exceptions to confidentiality with telehealth services, just as there are with in-person testing services. These include, but are not limited to, reporting child, elder, and dependent adult abuse and expressed threats of harm.
3. I understand that there are risks and consequences from telehealth testing services, including, but not limited to, the possibility, despite reasonable efforts on the part of WCPA that: the transmission of my information could be disrupted or distorted by technical failures, the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. In addition, I understand that telehealth based services and care may not be as complete as face-to-face services. My clinician cannot see me, my body language, or my non-verbal reactions to what we are discussing as clearly as may be seen in person. My clinician may not hear all of what I am saying and may need to ask me to repeat and clarify more often than during face-to-face discussions. Confidentiality is not as assured as it may be during face-to-face services.
5. I understand that I may benefit from telehealth testing services, but that results cannot be guaranteed.
6. I accept that telehealth services through WCPA does not provide emergency services. If I am experiencing an emergency situation, I understand that I can call 911 or proceed to the nearest hospital emergency room for help, or call my primary care physician or psychiatrist. If I am having suicidal thoughts or making plans to harm myself, I can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) or text 741741 for free, 24 hour hotline support.
7. I understand that I am responsible for providing the necessary telephone or internet-connected devices and internet access for my telehealth testing services and arranging a location with sufficient privacy that is free from distractions or intrusions.
8. I understand the same fee rates will apply for telehealth testing services as apply for in-person services. Although WCPA does not submit invoices for insurance payment, some testing clients may choose to submit these invoices for reimbursement after paying for WCPA services. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If I wish reimbursement, it is my responsibility to contact my insurance company prior to engaging in telehealth testing services in order to determine whether these services will be covered.
9. I agree that the telehealth testing services shall not be recorded in any way unless agreed to in writing by mutual consent. My clinician will maintain a record of our services in the same way (s)he maintains records of in-person services.
10. I understand that telehealth services through WCPA will only be conducted through telephone and/or online video services. Professional services will not be provided through email or text. Email and text communications with my clinician may only be used for setting or adjusting appointments.
11. I understand that I have additional rights and responsibilities, which are outlined in the document West County Psychological Associates Informed Consent for Testing Services, which I have also been provided.

By signing below, I acknowledge that I have both read and understood the information in this document and in West County Psychological Associates Informed Consent for Testing Services, and agree to the terms of both documents. This consent ends when I notify my clinician that I am terminating telehealth testing services or one year following my receipt of the written report describing my testing results.

In the case of a minor client, the signature of a parent is required.

NOTE: If parents are divorced or legally separated, the signatures of both parents are required unless otherwise stated in the legal parenting plan.

Good Faith Estimate for Health Care Services

Summary of Expected Charges:

Provider Name: Amy Maus, MSW, LCSW
Service: Psychoeducational evaluation
Diagnostic Code: To be determined (TBD)
Fee per hour: $190
Expected total fees: $1,600 – $2,200 per evaluation

Note: The total fee will be the number of hours of the evaluation multiplied by the hourly fee. The range of $1,600 to $2,200 is the best estimate at the outset of the process. Some clients test more quickly or slowly than others, and sometimes additional evaluation is necessary as more information becomes known. Therefore, an exact fee cannot be given in advance.

You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost.

• Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
• You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services.
• If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure to save a copy or picture of your Good Faith Estimate.
• For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

Disclaimer: This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS).

If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises. Keep a copy of this Good Faith Estimate in a safe place or take a picture of it.