PSYCHOLOGIST-PATIENT SERVICES AGREEMENT

Ruth m T Stemberger, Ph.D.,, LLC

  479 Jumpers Hole Road, suite 304B, Severna Park, MD 21146

Revised 1/1/2015

If you have an appointment scheduled,  please review these documents. If you agree to the terms and consent to treatment, please sign the agreement at the bottom of this page and bring a copy of the signature form with you to your first appointment.  Thank you.


Licensed Psychologist

Severna Park, Maryland


Welcome to my practice. This 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 new privacy protections and new 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.  Although I only provide services on a fee-for-service basis and  do not electronically provide PHI to your insurance company, it is recommended that all psychologists provide a Notice of Privacy Practices 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 any health care professional who electronically transmits your PHI must obtain your signature acknowledging that you have been provided with this information by the end of the first session; because I do not directly submit PHI to your insurance company, Because there may be times when it will be useful for me to mail, fax, or call in your PHI to your insurance company or to other health care professionals, it is recommended that I provide you with this information and obtain your signature indicating that I have done so. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.  That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.


PSYCHOLOGICAL SERVICES

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient and the particular problems you are experiencing. There are many different methods I may use in therapy, but I generally use cognitive behavioral methods to address the problems that my clients bring in to therapy.  I will explain these to you during the course of treatment.  Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.


Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress; but, there are no guarantees of what you will experience.


Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so it is important to be very careful about the therapist 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 refer you to another mental health professional for a second opinion.


Some psychological services that I do NOT provide include custody evaluations or court testimony, formalized academic assessment, and substance abuse treatment.  If you care in need of these services or if I recommend that you obtain them, I will refer you to another mental health professional from whom these services will be available.


MEETINGS

I normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we can both decide if I am the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, I will usually schedule one 45-minute session per week at a time we agree on, although some sessions may be longer or shorter, or more or less frequent. Once an appointment is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation [unless we both agree that you were unable to attend due to an emergency]. It is important to note that insurance companies do not provide reimbursement for missed sessions. If it is possible, I will try to find another time to reschedule cancelled appointments, but will still need to charge you for non-cancelled sessions. After the initial assessment and overall plan for treatment is complete, sometimes, patients are not able to make it to the session in person but are able to participate in a session over the phone.  It is important to understand that insurance companies usually do not reimburse patients for phone sessions.


PROFESSIONAL FEES

My fee is $175 for a 55 minute initial evaluation and $160 for subsequent 45 minute sessions. In addition to weekly appointments, I charge this amount for other professional services you may need, although I will break down the hourly cost if I work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, attendance at relevant meetings you have requested (eg., 504 or IEP meetings), transportation to a meeting or in-vivo session, preparation of records or treatment summaries, and the time spent performing any other service you may request of me and I agree to perform. If you become involved in legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, even if I am called to testify by another party.


Because of the difficulty of legal involvement, I charge $350 per hour for preparation and attendance at any legal proceeding.


CONTACTING ME

Due to my work schedule, I am often not immediately available by telephone. My office phone (410-315-9797) is a cell phone and has a 24 hour voice-mail recorder; I check these messages at least once per day and will do my best to return these calls within 48 hours.  If you are difficult to reach, please inform me of some times when you will be available.  In emergencies, contact your family physician or the nearest emergency room and ask for the psychiatrist or psychologist on call. If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact on my voicemail message.


Patients often request that I contact them via email or ask whether they are able to send me information or ask me questions via email.  As long as patients initiate this contact, I am usually willing and able to use email as a means of communication for limited types of information.  It is best to avoid addressing therapeutic issues via email except under certain circumstances, but using email for appointment scheduling or business issues can be helpful. However, it is important to be aware of the risk in using email to send private information: there is an increased risk of invasion of privacy when using email to convey information.   My computer and email accounts are password protected and I limit the use of identifying information in emails; I would encourage patients to do the same.  


Patients often prefer to use cell phone text messaging to communicate with me.  As long as patients have used text messaging to contact me or have given me permission to text message them, I will use text messaging to communicate. However, it is best to limit the use of text messaging to addressing issues such as scheduling or letting me know if you will be late for an appointment.  Using text messaging to address clinical issues is not advised.


LIMITS ON CONFIDENTIALITY

The law protects the privacy of all communications between a patient and a psychologist. 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 and/or Maryland law. However, in the following situations, no authorization is required:


·         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 patient. The other professionals are also legally bound to keep the information confidential. If you do not object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called “PHI” in my Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).

·         Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.

·         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 psychologist-patient privilege law. I cannot provide any information without your written authorization, or a court order.  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, I may be required to provide it for them.

·         If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.

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 patient’s treatment. These situations are unusual in my practice.


§         If I have reason to believe that a child or vulnerable adult has been subjected to abuse or neglect, or that a vulnerable adult has been subjected to self-neglect, or exploitation, the law requires that I file a report with the appropriate government agency, usually the local office of the Department of Social Services. Once such a report is filed, I may be required to provide additional information.

§         If I know that a patient has a propensity for violence and the patient indicates that he/she has the intention to inflict imminent physical injury upon a specified victim(s), I may be required to take protective actions that I believe are necessary to protect an intended victim. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the patient will carry out the threat, seeking hospitalization of the patient and/or informing the potential victim or the police about the threat.

§         If I believe that that there is a imminent risk that a patient will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the patient’s emergency health care needs, I may be required to take appropriate protective actions, including initiating hospitalization and/or notifying family members or others who can protect the patient.

    

If such a situation arises, I will make every effort to 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.


PRIVACY IN DATA STORAGE:  Please be aware of the potential risk to your privacy in data that I store for my practice:


____ My practice phone is a cell phone on which I can talk, text, and send and receive practice related emails.  I also access my gmail calendar for scheduling appointments on my phone.  These communications are protected by my passcode, but are not encrypted.  Therefore, they carry some risk of privacy breaches. For this reason, you may choose to limit the nature of the information you provide in phone calls, text messages and emails.  Your providing information in phone conversations, voicemails, text messages and emails is assumed to be an acceptance of that risk (i.e., if you wish to discuss a personal matter via these methods, you are agreeing to accept the risk of a breach and I agree to take the reasonable step of protecting your privacy with a passcode on my phone) ____My computer is used for emails and writing reports when applicable.  I also use it to access my gmail calendar on which I schedule appointments.  Data on this computer is encrypted each time the computer shuts down. It is de-encrypted when I turn it back on. 

____Patient contact information is stored on my cell phone and computer in a gmail contact list. This information is password protected, but is not encrypted.
​ ____Patient records are stored on paper in filing cabinets in my office. In accordance with Maryland law, these records are shredded 6 years after the last visit for adults over 21 and, for those who are under 21 when they first visit me, after age 21 or 6 years after the last visit, which ever comes later.




PROFESSIONAL RECORDS

You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your 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 is reasonably likely to endanger the life or physical safety of you or another 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 most circumstances, I charge a copying fee of $.16 per page and fees to cover sending the record to the appropriate party. 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.


PATIENT RIGHTS

HIPAA provides you with several 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 and the attached Notice of Privacy Practices. I am happy to discuss any of these rights with you.


MINORS & PARENTS

Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. While privacy in psychotherapy is very important, particularly with teenagers, parental involvement is often essential to successful treatment. Therefore, it is usually my policy to request an agreement from any patient between 16 and 18 and his/her parents allowing me to share general information about the progress of treatment and their child’s attendance at scheduled sessions. When appropriate, I may provide parents with a verbal summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Whenever possible,  I will discuss the matter with the child before discussing sensitive information with parents and do my best to handle any objections the teenager may have.


BILLING AND PAYMENTS

You will be expected to pay for each session at the time it is held. Payment schedules for other professional services will be agreed to when they are requested.   I do not have the capability to accept credit card payments.  I accept checks or cash for payment. I do not participate as a provider for any insurance companies, so any reimbursement your insurance company owes you should be sent directly to you.  I will provide you with a bill that contains the information you need to provide to your insurance company.


If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.  [If such legal action is necessary, its costs will be included in the claim.]


INSURANCE REIMBURSEMENT

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for my services if you have “out-of-network” benefits.  If you participate in an HMO, you probably will not be eligible to receive any reimbursement for my services.  Although I do not directly submit for insurance reimbursement, I will complete treatment plans and attempt to provide you with the assistance necessary for you to receive the benefits to which you are entitled; however, you are responsible for full payment of my fees. It is very important that you find out exactly what mental health services your insurance policy covers.


You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company.


Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end.


You should also be aware that your contract with your health insurance company may require that I provide it with information relevant to the services that I provide to you in order for you to receive the reimbursement you are entitle to under your plan.  If you request that I do so, I will fax this information to the.  They might require that I provide them with a clinical diagnosis additional clinical information such as treatment plans or summaries. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested.  Maryland law prevents insurers from making unreasonable demands for information, but there are no specific guidelines about what unreasonable includes.  If I believe that your health insurance company is requesting an unreasonable amount of information, I will call it to your attention and we can discuss what to do. You can instruct me not to send requested information, but this could result in claims not being paid and an additional financial burden being placed on you. Once the insurance company has this information, it will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing that you have read this Agreement, you agree that I can provide requested information to your carrier.

                                        __________________________________________________________________________________________________



                                                                                                            Notice of Privacy Practices

                                                                                                           Ruth M.T. Stemberger, Ph.D.


THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.


I.  Uses and Disclosures for Treatment, Payment, and Health Care Operations


I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help clarify these terms, here are some definitions:

·         “PHI” refers to information in your health record that could identify you.

·         “Treatment, Payment, and Health Care Operations”

– Treatment is when I provide, coordinate, or manage your health care and other services related to your health care.  An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

– Payment is when I obtain reimbursement for your healthcare.  Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

– Health Care Operations are activities that relate to the performance and operation of my practice.  Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

·         “Use” applies only to activities within my [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

·         “Disclosure” applies to activities outside of my [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

·         “Authorization” is your written permission to disclose confidential mental health information.  All authorizations to disclose must be on a specific legally required form.


II.  Other Uses and Disclosures Requiring Authorization


I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained.  In those instances when I am asked for information for purposes outside of treatment, payment, or health care operations, I will obtain an authorization from you before releasing this information.  I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record.  These notes are given a greater degree of protection than PHI.


You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.


III.  Uses and Disclosures without Authorization


I may use or disclose PHI without your consent or authorization in the following circumstances:

·         Child Abuse – If I have reason to believe that a child has been subjected to abuse or neglect, I must report this belief to the appropriate authorities.  I am also required to report any cases of sexual abuse, even if the person who was abused is now an adult.


·         Adult and Domestic Abuse – I may disclose protected health information regarding you if I reasonably believe that you are a victim of abuse, neglect, self-neglector exploitation.


·         Health Oversight Activities – If I receive a subpoena from the Maryland Board of Examiners of Psychologists because they are investigating my practice, I must disclose any PHI requested by the Board.


·         Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and I will not release information without your written authorization or a court order.  The privilege does not apply when you are being evaluated or a third party or where the evaluation is court ordered.  You will be informed in advance if this is the case.


·         Serious Threat to Health or Safety – If you communicate to me a specific threat of imminent harm against another individual or if I believe that there is clear, imminent risk of physical or mental injury being inflicted against another individual, I may make disclosures that I believe are necessary to protect that individual from harm.  If I believe that you present an imminent, serious risk of physical or mental injury or death to yourself, I may make disclosures I consider necessary to protect you from harm.


IV.  Patient’s Rights and Psychologist’s Duties


Patient’s Rights:

·         Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information.  However, I am not required to agree to a restriction you request.

·         Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.  (For example, you may not want a family member to know that you are seeing me.  On your request, I will send your bills to another address.)

·         Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed.  You have the right to inspect or obtain a copy (or both) of Psychotherapy Notes unless I believe the disclosure of the record will be injurious to your health.  On your request, I will discuss with you the details of the request and denial process for both PHI and Psychotherapy Notes.  

·         Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record.  I may deny your request.  On your request, I will discuss with you the details of the amendment process.

·         Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI.  On your request, I will discuss with you the details of the accounting process.

·         Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.


Psychologist’s Duties:

·         I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

·         I reserve the right to change the privacy policies and practices described in this notice.  Unless I notify you of such changes, however, I am required to abide by the terms currently in

effect.

·         If I revise my policies and procedures, I will provide you with a copy of the revised policies either in session or by mail as long as your record remains active (i.e., your record will remain active while you are in treatment and at any point when you contact me in the future regarding release of your PHI).


V.  Questions and Complaints


If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me.

If you believe that your privacy rights have been violated and wish to file a complaint with me office, you may send your written complaint to my office

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services.

You have specific rights under the Privacy Rule.  I will not retaliate against you for exercising your right to file a complaint.


VI.  Effective Date, Restrictions, and Changes to Privacy Policy


This notice will go into effect on April 14, 2003.


I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain.  If I change the terms of the notice, I will provide you with a copy of the revised policies either in session or by mail as long as your record remains active (i.e., your record will remain active while you are in treatment and at any point when you contact me in the future regarding release of your PHI).



 _____________________________________________________________________________________


                                                                                                                      SIGNATURE FORM


                  Your signature below indicates that you have read the information in the Notice of Privacy Rights and the Psychologist-Patient Services Agreement documents

                                                                                  and agree to abide by their terms during our professional relationship.


( NOTE For Parents or Legal Guardians who have joint custody: All parents or guardians who share custody must agree to the terms in the agreement and indicate their agreement with their signature in order for your child to been seen for therapy.  Your signature indicates that you have informed me of any other legal custodians of your child so that they can also review the agreement and determine whether they agree to it.)



                                                                                                                                                                                                              

Patient, Parent, or Legal Guardian Signature


                                                                                                                                                                                                               

Parent or Legal Guardian Signature  (Two parent signatures are required only if parents are divorced and have joint legal custody)



                                                                                                                                                                                                               

Psychologist Signature


                                                               

Date