HIPAA Privacy Notice

Updated: 11/22/22

Our 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.

 

How I May Use and Disclose 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 the ways I am permitted to use and disclose information will fall within one of the categories.

  1. 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 person health information, which is otherwise confidential, to assist the clinician in diagnosis and treatment of your mental health condition.

  2. Disclosures for treatment purposes are not limited to the minimum necessary standard. Therapists and other health care providers need access to the full record and/or full and complete information 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.

  3. 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.

 

Certain Uses and Disclosures Require Your Authorization

  1. 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:

    • For my use in treating you.

    • 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.

    • For my use in defending myself in legal proceedings instituted by you.

    • For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

    • Required by law and the use or disclosure is limited to the requirements of such law.

    • Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

    • Required by a coroner who is performing duties authorized by law.

    • Required to help avert a serious threat to the health and safety of others.

  2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.

  3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

 

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:

  1. 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.

  2. 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.

  3. For health oversight activities, including audits and investigations.

  4. 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.

  5. For law enforcement purposes, including reporting crimes occurring on my premises.

  6. To coroners or medical examiners when such individuals are performing duties authorized by law.

  7. 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.

  8. 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.

  9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI 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.

 

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.

 

You Have the Following Rights with Respect to Your PHI

  1. 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.

  2. 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.

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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 to maintain HIPAA Compliance

  1. Simple Practice: Contains medical records, scheduling, insurance processing, credit card process, secure documentation and HIPAA compliant messaging and client portal.  Nova Telemental Health LLC maintains a Business Associate Agreement.

  2. Iplum: HIPAA Compliant Online Fax service, Nova Telemental Health LLC maintains a Business Associate Agreement.

  3. Psychology Today: Client referral services. Nova Telemental Health LLC maintains a Business Associate Agreement.

  4. Doxy: HIPAA Compliant Video Conferencing Platform, each clinician maintains their own Business Associate Agreement.

  5. Zoom: Any clinician using HIPAA Compliant Zoom maintains their own Business Associate Agreement.

  6. Google Workplace: Nova Telemental Health LLC maintains a Business Associate Agreement.

  7. Virtru: Additional protection including end to end email encryption overlaid with Google Workplace/Email/Drive. Nova Telemental Health LLC maintains a Business Associate Agreement.

 

 

Practice Policies

Consent for Telemental Health Consultation and Sessions


Your agreement to the following terms and conditions is required for you/your child to receive professional services from Nova Telemental Health. If you do not agree, we will be glad to give you referrals to other providers. Your consent for yourself/your child to receive a comprehensive diagnostic assessment. At the end of the evaluation, we will mutually decide if we will continue treatment together.

 

Jurisdiction for Treatment
Nova Telemental Health LLC is currently only operating in Virginia. For the purposes of your telehealth sessions, you must be in Virginia at the time of services. This is non-negotiable and subject to Virginia law, not the clinician’s discretion. If you are outside of your home address, you will need to provide your clinician with your current address, or if parked in your care, the nearest address to you. If you are in your car, it must be parked and your clinician will ask you for the make, model, and license plate and nearest cross street. The only current exception: Kelly Cipera is licensed in both Virginia and Ohio.

 

Psychological Services

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychotherapist and client, and the particular concerns that you are experiencing. There are many different methods that Nova Telemental Health clinicians may use to deal with the concerns that you hope to address. 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 the most successful, you will have to work on the things that 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. However, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific concerns, and significant reductions in feelings of distress. There are no guarantees of what you will experience.

 

Who to Contact

  • Kelly Cipera, LCSW is our Founder and Executive Director and Clinical Supervisor.

    • Email: kelly@novatmh.com

    • Phone: 571-469-7106

    • Fax: 571-307-2823

    • Please understand that due to my work schedule I am often not immediately available by telephone or email. I will not answer a phone call, text or email when I am with a client. I will make every effort to return your call, text or email on the same day, except for weekends or holidays.

  • Administrative Director Ashleigh Beckman

    • Billing, Scheduling, Medical Records and Administrative Support

    • Email: admin@novatmh.com

 

Residents/Supervisees

Residents Supervised by Kelly Cipera, LCSW

  • Shealyn Clinger, MSW Supervisee in Social Work

  • Schlese Castilla, MSW Supervisee in Social Work

 

Residents Supervised by Christa Butler, LPC, TF-CBT, RPT.

  • Nicole Crennan, MA Resident in Counseling

  • Supervisor Contact Information: 703-879-0654; christanb87@gmail.com

 

Working with Supervisee has the added benefit of the experience and support of their supervisor. There are limits to confidentiality when working with a Supervisee/Resident because it is imperative to their learning to engage in case consultation while they develop their therapeutic skills. Nova Telemental Health prides itself in providing extensive training and support to our Residents and we believe they are more than qualified to meet your clinical needs. If you have any questions or concerns you may reach out to Kelly Cipera as the Practice Owner or the Resident’s Clinical Supervisor.

Consent to Telehealth Consultation and Sessions

I understand that:

  1. My Clinician plans on conducting therapy session over a HIPAA Compliant audio and visual telemedicine platform (Zoom, Doxy, Simple Practice).

  2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

  3. Telehealth therapy session has potential benefits including easier access to care and the convenience of meeting from a location of my choosing. In addition, confidentiality cannot be maintained if you participate in therapy in public spaces using telehealth services.

  4. There are risks and consequences from telemental health, including, but not limited to: the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical 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.

  5. I will have a conversation with my provider, during which I had the opportunity to ask questions regarding this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

  6. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

Specific Policies for Telemental Health Sessions

  1. Telehealth is considered synchronous audio and visual communication. In many cases insurances will not cover therapy sessions conducted without the video component. It is your responsibility to confirm with your insurance policy if you are going to request an audio only appointment.

    • A telemental health appointment should be conducted as an in-person appointment.

    • Safety is paramount.  You cannot be driving or in a moving vehicle.  You should not be in a public place, walking, or engaging in other activities at the time of the session.

    • Both parties will be expected to be dressed in appropriate attire and behave as though we are sitting in an office.

    • Maintaining a private setting where you are alone,

    • Not engaging in other forms of media during the appointment such as watching tv, playing video games, or listening to music unless discussed with therapist in advance.

    • Refraining from drugs, alcohol, or other substances/activities that would distract from the therapy session.

  2. If during an appointment a client behaves in an inappropriate manner, the client will be terminated immediately and/or reported to authorities.

  3. There will be no recording of any of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.

  4. If you are having suicidal or homicidal thoughts, actively experiencing psychotic symptoms, or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.

  5. While we try to accommodate clients of all ages, telehealth is often not appropriate for minors under the age of 14.  Your clinician will meet with the minor and decide if telehealth is appropriate during their initial assessment.  If they are deemed inappropriate for telehealth you/your child will be provided with referrals and discharged from future services.

Telehealth Emergency Situations

  1. Emergency Contacts: If, during a regular therapy session there is a physical or mental health emergency, your therapist will contact emergency services or your telemental emergency contact. If you are not in immediate need for a higher level of care or assistance, you clinician will discuss with you who to call for further assistance, using the telemental emergency contact form you completed. Your clinician will provide only the minimum necessary information to protect your health, safety, and privacy. The intent is that this person could prevent needing additional services or to support you until emergency services can arrive on the scene.

  2. Location: You must disclose your location at the beginning of every session in the event of an emergency your therapist will need to know where to send emergency support. Be prepared to share your address if in a building, or cross street information as well as your vehicle information if you are parked in your car.

  3. Telemental Health Emergency Contacts: It is considered best practices to maintain two local area emergency contact people on file, with the limitations that they will only be contacted in the event you need immediate assistance up until emergency personnel can be called to your location or if their assistance can prevent the need for a higher level of care.

  4. Opting Out: You may opt out of providing any emergency contact person. In the event of an emergency, your local emergency phone number will become your emergency contact. You must select a local emergency room and local non-emergency line for law enforcement.

  5. If you become unconscious, unable to answer, or are otherwise incapacitated, emergency services will be called immediately.

  6. Minimum Necessary Rule: HIPAA Privacy Rules are maintained and designating someone as an emergency contact does not constitute an Authorization for a Release of Information for any other information.

  7. Emergency Service: HIPAA regulations allow your clinician to share the minimum necessary information needed to emergency responders to maintain your safety. This information will include: Your current location, known allergies, known medications, known medical issues but not personal information related to treatment.

Appointments

  1. The initial appointment is generally a 60-minute appointment, please be prepared to spend the hour with your therapist.

  2. Appointment times will be determined between you and your individual therapist.  Standard appointment increments are:

    • 90832 – Psychotherapy, 30 minutes (16-37 minutes).

    • 90834 – Psychotherapy, 45 minutes (38-52 minutes).

    • 90837 – Psychotherapy, 60 minutes (53 minutes and over)

    • 90846 – Family or couples psychotherapy, without patient present. (26+ minutes)

    • 90847 – Family or couples psychotherapy, with patient present. (26+ minutes)

    • 90853 – Group Psychotherapy (not family).

  3. Other appointments, and time increments may be available, but may not be covered by insurance, please discuss with your therapist. You will be responsible for paying for any service not covered by your insurance. When in doubt, call the member services phone number on your insurance card to verify eligibility If your insurance pays for part of the service but denies time extension you may be responsible for the additional time. (Examples: Relationship Therapy, Sex Therapy, Extended Sessions 90+ minutes)

  4. Crisis appointments or appointments made outside of normally scheduled hours may incur additional costs associated with copayments, coinsurance, or deductibles, the client agrees to be responsible for these costs. Crisis appointments are defined by this practice as: Any appointment made outside of normal scheduled time, that would require your Clinician to add or modify their schedule to see you. Nova Telemental Health LLC and its clinicians are not considered crisis service providers, your therapist may refer you to emergency services after a crisis appointment is initiated.

  5. Nova Telemental Health LLC and its clinicians are not considered crisis services, your therapist may refer you to emergency services after a crisis appointment is initiated.

  6. Mental Health Emergency Situations: In the event of a medical or mental health emergency, please dial 9-1-1 or go to your local emergency room. Our Clinicians are not required to be available outside of their business hours and may not be reachable. Nova Telemental Health LLC does not have an answering or “on-call” service.

 

Client Initiated Cancellations

  1. Please remember to cancel or reschedule 24 hours in advance.

  2. Late arrivals (15+ minutes late), Late Cancellations, and failure to show to a session will be subject to a fee of $100.  Your clinician is not obligated to conduct appointments that begin 15 minutes past the start time.

  3. In the event of an emergency, your clinician may waive the fee. This is up to the individual clinician’s discretion and practice management will not provide waivers on behalf of your clinician.

  4. Excessive cancellations (general threshold is 3 missed appointments) can result in losing your appointment time or being discharged from services. You will be provided a minimum of 3 referrals, if therapy is still indicated. This is at the clinician’s discretion. Practice Management will not overturn the clinician’s decision

  5. Reinitiating services is at the discretion of the clinician.  Your clinician may work with you to create a written plan to address late cancellations or failing to show for appointments, but this is at their discretion based on the concerns being addressed in therapy.

 

Clinician Initiated Cancellations

  1. Your clinician will make every effort to afford you the same courtesy of canceling an appointment with 24-hour notice when possible.  Just as we understand you will have emergencies from time to time, or other issues arise we will do our best to communicate as soon as possible.

  2. Discuss with your clinician their policy for days that have school closures, government closures, holidays, etc.  Each clinician is at their discretion for how they will handle these times off.

Termination/Discharge from Treatment

  1. After appropriate discussion with you with referrals to any additional supportive services. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating.

  2. If you require a higher level of care or specialized care as evidenced by self-report, clinical interview, or behavior evidenced in sessions. Appropriate referrals and supports will be provided to client at this time.

  3. Some clients are not appropriate for telehealth (age, attention, condition, or any other reason deemed by the therapist) and may be referred out to practices who can accommodate your needs.

  4. Therapy is only effective if you attend and are willing to work, if it is determined that the psychotherapy is not being effectively used or if there is a clear pattern of late-cancellations or failure to show for the scheduled session, you may be discharged with referrals.

  5. The practice policy is after three no-show/late-cancellations appointments you can be discharged from services. Your clinician may alter this policy, but this will require written consent and a plan between you and your therapist to reduce future occurrences of missed appointments.

  6. If you are in default on payment treatment can be paused or terminated. Efforts will be made to collect owed payments before sessions can resume. If your personal balance is above $100 a payment plan will need to be discussed with Practice Management. This does not include insurance balances.

  7. Therapy can be terminated by client for any reason, or you may request another therapist. Your discharge request will be responded to promptly and referrals provided as necessary.

If you are in a suicidal crisis, treatment will not be terminated even for failure to pay. Once the crisis has resolved, clinician and client will have to determine correctness of fit, need for additional or higher levels of care.

Communication Between Client and Clinician

All client communication will be documented in the client's clinical chart.

  • Telehealth Sessions: Each clinician within this practice maintains their own HIPAA Compliant audio and visual conferencing platform or uses the Simple Practice Platform for sessions. Other audio/visual platforms may not be secure, encrypted or HIPAA compliant. The practice maintains all necessary Business Associate Agreements in compliance with telehealth standards.

  • Email Communication: Your Clinician has a company email with the ending @novatmh.com. These emails are protected with additional encryption through Google Workplace. While our email meets the qualifications for HIPAA it is not a replacement for attending your regularly scheduled sessions. Email should not be used to discuss therapeutic topics and this is not considered part of the therapeutic services being provided. We encourage you to journal, takes notes, or otherwise document ideas between sessions, request additional sessions, or we may need to consider a higher level of care.

  • Client Portal: Access our client portal using the email address we have on file at this address: https://novatmh.clientsecure.me/sign-in or by clicking the Client Portal link at the top of our website. This is the preferred method for messaging your therapist. The Client Portal is where you may access invoices, signed paperwork, your upcoming schedule with your clinician, upload documents to your client chart, and securely message your Clinician.

    Telephone: Please leave a voice mail requesting a call back. This practice does not have an on-call or administrative service to answer calls on behalf of your clinician. Phone calls and voicemail are not suitable alternatives to therapy sessions and any phone calls or voicemails that include therapeutic information will be noted within the client’s medical record. Excessive phone calls, or length of calls will incur a fee, as outlined in the Fees section of this agreement.

  • Texting: Texting your therapist is discouraged because there is no reasonable way to ensure complete HIPAA privacy compliance. Check with your therapist to see if they allow you to text them. The client portal should be your preferred way to access your Clinician. Texting should not be used to discuss therapeutic topics and this is not considered part of the therapeutic services being provided.

  • Social Media This practice participates in LinkedIn, Psychology Today, and Google Business and other marketing forums. It may engage in other forms of social media in the future.

    • This practice will never identify clients, the family of clients, or anyone known to be an associate of a client on these social media platforms.

    • Your clinician will not accept social media requests to friend or follow your on any social media platform to protect your privacy.

    • If you identify yourself as a client of this practice or of a specific clinician, you are doing that of your own volition and will never be asked to participate in reviews, testimonials, or to join any social media on behalf of this practice.

    • You may provide reviews or testimonials if you wish, but you accept the risks and benefits of identifying yourself as a client.

    • Social media should not be used in any form to contact your therapist, these websites are not secure and do not conform with HIPAA regulations.

If you have questions, you can bring them to session with your clinician.

Payment

  1. Due at Time of Service: Clients will be fully responsible for all copayments, coinsurance payments, or deductible payments. Copayment/Coinsurance/Deductible/Session Fee payments are due at time of service.

  2. Insurance Recoupments: If your insurance recoups the cost of any attended session, the client will be responsible for resolving the concern or repaying the clinician.

  3. You MUST verify your own insurance benefits: We make every attempt verify your insurance benefits ahead of your appointment, but you are responsible for knowing if you are eligible for mental health services and what services are covered under your policy. You will be responsible for any fees related to rejected or denied insurance claims. If your insurance refuses to pay due to lack of coverage, changes in coverage, denial, rejection or other reason that cannot be resolved, the client is responsible for the remaining balance.

  4. Credit Card on File: We require a credit card to be kept on file for the purposes of paying fees, co-payments/co-insurance/deductible or other related service fees.

  5. Negative Account Balance: All client balances must be paid at the time of service. If you owe $100 or more, that balance must be paid 24 hours before your next appointment. Future appointments may be cancelled until the balance is resolved.  Payment plans and sliding scale are available, but you must request.

  6. Collections: We will make every reasonable effort to collect any unpaid balance to help you avoid accruing a balance and reserve the right to cancel your future appointments until that balance is paid. Excessive unpaid balances may be sent to collections if necessary.

  7. Delinquent Credit Card Payment Policy: If your credit card declines or has insufficient funds you will need to provide a new card 24 hours before your next appointment.  Failure to do so will result in your appointment being cancelled and a no-show fee of $100 applied to your account.  If you are concerned this may be an issue you are encouraged to maintain a positive balance (paying one copay or one session fee ahead).  At termination of treatment, any positive balance will be refunded.

 

Fees

 

Insurance

If you have insurance, you will have a negotiated rate which will be less than these posted rates. If you have a deductible you are paying, you will be responsible for the full negotiated rate, NOT the out-of-pocket rate. We ask that if you have insurance, we first evaluate your costs based on our negotiated rates with your insurance.  If you are opting out of using insurance we will be charging the full fee below and proving you a superbill to be reimbursed by your insurance out of network benefits.

 

Clients are responsible for confirming their deductible and copay. We endeavor to get this information in advance but do not always get reliable information. Please confirm your mental health benefits independently before the start of services. Claims denied will be the client’s responsibility to pay.

 

Out of Network/Out of Pocket Fees for Service Nova Telemental Health LLC recognizes there may be many reasons you would not want to use insurance benefits or do not currently have insurance benefits. In this case you will be responsible for the posted fees per session. If you choose to pay out of pocket and you have insurance, you will be asked to complete an “Insurance Opt-Out” form.

 

Sliding Scale fees are available on a case-by-case basis and are ultimately at the discretion of the individual clinician. If it is determined that Sliding Scale is appropriate, you will be asked to sign a “Sliding Scale Agreement” to activate the current sliding scale rates. Our sliding scale rates are meant to be temporary and should be re-evaluated at regular intervals with your therapist or if your financial situation changes/new insurance is obtained. It is not meant to be permanent, if possible.​

 

No-Show/Late Cancellation Fees are $100 unless the individual clinician has waived the fee.

Letter Writing Fee: $25 per 15 Minutes (may vary by clinician, ask your clinician) -Examples of Letters or Forms include: School Accommodation Letters, Social Security Disability Forms, Letters to Insurance Companies, Health Providers (outside normal PCP Care Coordination Letters), etc.

Phone Calls over 15 minutes: $25 per 15 minutes if not billable by insurance.

Attendance at Meetings outside Therapy (virtual or in person): $150 per hour.

Full Medical Records Request: $25. If you are requesting your complete medical record, which will take time to prepare we ask for 7 calendar days to complete the request. If you are requesting a summary, diagnosis, letter, discuss with your therapist.

 

Court Appearance: Clients are discouraged from having the therapist subpoenaed. The party requesting the Clinician’s appearance or support will be responsible for all fees.  If the party is not the client and refuses to pay, it will then become the Client’s responsibility to pay. There is no guarantee the therapist's testimony will be solely in in the client's favor. The Therapist will only testify their professional opinion and to the facts of the case. The following fees apply for court appearances but may not be exhaustive:

  • Preparation time (including submission of records) $220/hour

  • Phone calls $220/hour

  • Depositions $250/hour

  • Email or written letters $200/hour

  • Time required in giving testimony $250/hour

  • Mileage $0.63/mile (mileage based on annual irs.gov recommendations)

  • Time away from office due to depositions or testimony $220/hour

  • Filing a document with the court $100 (Plus court fees)

  • The minimum charge for a court appearance $3000

  • Any and all legal fees and costs incurred by the therapist as a result of the legal action.

PLEASE NOTE: A retainer of $3000 is due in advance. If a subpoena or notice to meet attorney(s) is received without a minimum of 48-hour notice, there will be an additional $250 “express” charge. If the case is reset with notice of less than 72 business-hours, the client will be charged $500 (in addition to the retainer of $1500). All fees are doubled if the therapist has to postpone or interrupt plans to go out of town. If your clinician is a resident, their immediate clinical or administrative supervisor will also be required, and additional fees will apply.

Minors in Treatment

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/Discharge from Treatment

Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment.

 

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