Privacy and Practice Policies

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

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office, and on my website.

II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
c. For my use in defending myself in legal proceedings instituted by you.
d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
e. Required by law and the use or disclosure is limited to the requirements of such law.
f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION.
Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
10 Appointment reminders and health related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

Practice Policies

Notice of Privacy Practices

The following policies are designed to help ensure that our work together runs smoothly and that expectations are clear for both of us. Please take a few moments to review them carefully. If you have any questions, I am always happy to discuss them.

PAYMENT AND FEES

I accept several major insurance plans. Please contact me or visit my website (www.forestferncounseling.com) for the most current list of accepted insurance providers. Depending on your insurance plan, you may be responsible for a copay, coinsurance, or deductible. I also accept self-pay (no insurance involved). My self-pay fee is $140 per session.

A valid credit, debit, or HSA card is required to be kept on file through the secure client portal. The card on file may be used to process payments for session fees, copays, coinsurance, deductibles, cancellation fees, or any outstanding balances.

For self-pay clients, the session fee will be charged to the card on file following each session.

For clients using insurance, copays, coinsurance, or deductible amounts may be charged to the card on file after your session. Because insurance claims are processed after services are provided, any remaining balance after insurance processes may also be charged to the card on file.

Clients may submit copayments through the client portal at the time of their session. If payment has not been received within 24 hours, the card on file may be charged. If a card is declined or a balance remains unpaid, I will notify you so that payment can be resolved. Ongoing sessions may be paused if balances remain outstanding.

Payment exceptions may occasionally be considered if discussed in advance and approved by the therapist.

INSURANCE BENEFITS

As a courtesy, I may assist with verifying your insurance benefits. However, insurance verification is not a guarantee of coverage or payment.

Your insurance policy is a contract between you and your insurance company, and you are ultimately responsible for understanding your benefits, including copays, deductibles, coinsurance, and any services that may not be covered. If your insurance company determines that a service is not covered or applies the cost toward your deductible, you are responsible for the remaining balance.

GOOD FAITH ESTIMATE

Under federal law, healthcare providers are required to provide clients who are not using insurance with a “Good Faith Estimate” of the expected cost of services.

You have the right to receive a Good Faith Estimate explaining how much your medical and mental health care may cost if you choose not to use insurance.

Upon request, you may receive an estimate of the total expected cost of any non-emergency services, including psychotherapy sessions. The estimate will include expected charges for the services provided.

If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

You may ask for a Good Faith Estimate before scheduling a service or at any time during treatment.

For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.

APPOINTMENTS AND CANCELLATIONS

The standard psychotherapy session is 55–60 minutes. If you would like to request a different session length, this must be discussed with the therapist in advance so time can be scheduled appropriately.

If you need to cancel or reschedule a session, please provide at least 24 hours notice. Sessions canceled with less than 24 hours notice may be charged a $50 cancellation fee to the card on file. This policy exists because your appointment time is reserved specifically for you and cannot usually be offered to another client on short notice.

I allow up to two late cancellation grace occurrences within a 12-month period. The fee may also be waived if you are able to reschedule your session within the same calendar week, depending on availability.

If you arrive late for your session, the session will still end at the scheduled time.

CONSISTENCY OF ATTENDANCE

Regular attendance is an important part of the therapeutic process. Consistent sessions help build momentum and support meaningful progress in therapy.

If a significant amount of time passes without scheduling a session, I may reach out to check in. If I do not hear from you and no sessions are scheduled for 60 days, the therapeutic relationship may be considered inactive. If your chart becomes inactive, you are welcome to reach out in the future to discuss scheduling, depending on current availability.

If you plan to take a break from therapy or change the frequency of sessions, we can discuss this together so that care can continue in a way that best supports your needs.

COMMUNICATION BETWEEN SESSIONS

If you need to contact me between sessions, please leave a message on my voicemail, send me a text message, or send a message from your secure client portal. I am often not immediately available; however, I will attempt to return your call within 24 hours. Please note that face-to-face video sessions are highly preferable to phone sessions. However, in the event that you are out of town, sick, or need additional support, phone sessions may be available.

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so.

While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. If a true emergency situation arises, please call 911 or any local emergency room.

If you choose to use information technology for some or all of your treatment, you need to understand that:

You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available. I will be keeping record notes of all our sessions and phone conversations. These notes will contain clinically-descriptive and non-judgmental information that we discuss in our sessions. These notes allow us to track your progress and document what has occurred during sessions. If you would ever like to access your file, ask me and we will discuss how that needs to be handled.

If you are the parent/legal guardian of a child/adolescent, you have access to the record. Please ask me if you are interested in part of the record and we will discuss how this needs to happen. In order to speak for you to other agencies or people, I need a signed release of information from you.

MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure if possible. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.