CLIENT SERVICES AGREEMENT WELCOME TO MY PRACTICE! * This Client Services Agreement contains important information about my professional services and business policies. It also contains information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and client rights regarding the use and disclosure of your Protected Health Information (PHI) for the purpose of treatment, payment, and health care operations HIPAA requires that we provide you with a Notice of Privacy Practices (see separate form), which explains the application of HIPAA to your PHI in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will represent an agreement between you and Monya Cohen, Psy.D., LLC. You may revoke this Agreement in writing at any time. That revocation will be binding on us unless we have acted in reliance on it; if there are obligations imposed on us 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. I Understand I Do Not Understand PSYCHOLOGICAL SERVICES * Psychotherapy cannot be described in general terms. It varies depending on the presenting concerns you or your teen are experiencing. There are different methods we may use to deal with the problems being experienced. Psychotherapy calls for an active effort on the part of the client. To increase the likelihood of success, it is important that you work on the things that we talk about both during and between sessions. Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspect of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has shown significant benefits in improving relationships, finding solutions to specific problems, leading to significant reductions of distress, and improving general quality of life. But there are no guarantees of what you will experience. I do not believe that there is one size that fits everyone. By the end of the intake evaluation, we will be able to discuss initial clinical impressions and therapeutic goals. I invite you to evaluate this information along with your own assessment about whether you feel comfortable working with me. I will also determine whether I am the appropriate therapy provider for your needs. Therapy involves a commitment of time and energy, so you should be very careful about the clinician you select. If you have questions about my procedures, let's discuss them whenever they arise. If your doubts persist, I am happy to help you secure an appropriate consultation with another mental health professional. I Understand I Do Not Understand BILLING AND PAYMENTS * You will be expected to pay the co-payment or out-of-pocket fee for each session at the time it is held. I ask that you complete the credit card authorization form that allows us to charge your credit card for the co-payment or out-of-pocket fee following the session. There are some insurance plans that require you to pay a deductible at the beginning of the calendar year. We will charge your credit card for the therapy until the deductible has been met. We will notify you prior to this happening and typically you have been notified by your insurance carrier. Unless a session is cancelled 24 hours in advance, you will be charged the full amount your insurance company reimburses me for a missed appointment. I understand that life happens and an individual or family crisis. illness, or medical emergency may require you to cancel your appointment at the last minute. I handle these situations on a case-by-case basis. Please note that should you cancel three or more consecutive sessions; I will no longer be able to guarantee your regular appointment time. I Understant I Do Not Understand INSURANCE * Monya Cohen Psy.D., LLC is an approved provider for most Blue Cross Blue Shield and Cigna insurance Plans. Prior to meeting with me for a consultation, I request that you email me a photo of the front and back of your insurance card and my billing person will review your coverage. This requires that you provide me with the full name and date of birth, and mailing address of the client, and the full name, date of birth, and mailing address of the primary card holder. Please note that your contract with your health insurance company requires that we provide information relevant to the services that we provide to you if you submit claims. Maryland permits me to send some information without your consent to process and file appropriate claims. I am required to provide them with a clinical diagnosis and information typically limited to the Uniform Treatment Plan. There may be times (rarely) that I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. 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 bring it to your attention. You can instruct me not to send the 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 your claim information, it will become part of the insurance company files. 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 we submit if you request it. By signing this Agreement, you agree that we can provide requested information to your insurance carrier. You are solely responsible for payment to Monya Cohen, Psy.D., LLC, and if you have a conflict with your insurance carrier, it is your responsibility to resolve it directly with your carrier. You also agree that you will not hold Monya Cohen, Psy.D., LLC responsible for any disputes that arise between you and your insurance carrier. I Understand I Do Not Understand CONTACTING ME * When I am unavailable, because I am in session or out of the office, the best way to reach me is by email at dr.monyacohenyoga@gmail.com. I will make every effort to return your email within 24 hours, except for weekends and holidays. If you are unable to wait 24 hours for a return email, please let me know the urgency of your situation and I will return your email or phone you as soon as I am able. In case of an emergency, call 911, your local crisis center, or go to the nearest emergency room. I Understand I Do Not Understand LIMITS ON CONFIDENTIALITY * The law protects the privacy of all communications between a client and a clinician. In most situations, I can only release information about your treatment to others if you sign the written Authorization Form that meets legal requirements imposed by HIPAA and/or Maryland law. However, in the following situations, no authorization is required to disclose protected health information: *You should be aware that I am a solo practitioner and work with a professional billing services. For administrative purposes such as scheduling and billing, I need to share protected information with my billing person. Occasionally, I may 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 identify of the client. The other professionals are also legally bound to keep the information confidential. If you do not object, we will not tell you about these consultations unless we feel that it is important to our work together *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 doctor-client privilege *I cannot provide any information without your written authorization, a properly served subpoena that is not objected to on your behalf, or a court order, unless your mental health is an element of your claim or defense. In cases of separation/divorce/custody, a Best Interest Attorney or a Privilege Attorney would make the determination of release of privileged information. 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 the information. If a government agency is requesting information for health oversight activities, I may be required to provide it for them. If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client to defend my practice. There are some situations in which I am legally obligated to take action, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a client'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 we know that a client has a propensity for violence and the client 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. These actions may include establishing and undertaking a treatment plan that is calculated to eliminate the possibility that the client will carry out the threat, seeking hospitalization of the client and/or informing the potential victim and/or the police about the threat. *If I believe that there is an imminent risk that a client will inflict serious physical harm or death on him/herself, or that immediate disclosure is required to provide for the client'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 client. If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit our disclosure to what is necessary. Except for situations in which I am legally required to breach confidentiality, you agree that I may use my professional judgment to determine what is and what is not shared with parents of child/minor clients. This allows minors (particularly adolescents) to participate in therapy without feeling at risk of having their personal information shared with parents. This creates a private, therapeutic environment, and offers a respectful attitude to my teenage clients. I welcome any questions or concerns about this aspect of my practice. While this written summary of exceptions to confidentiality should prove useful in information you about potential problems, it is important that we discuss any questions or concerns that you may have not 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. I Understand I Do Not Understand MINORS & PARENTS * Clients under 18 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. You agree that I can use my professional judgment to determine what is and what is not shared with parents of child/minor clients. I will also provide parents with a summary of their child's treatment if requested and we have permission from both parents. If I feel that the child is in danger or is a danger to someone else, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have. In cases where there are disputes between parents (i.e., contested custody, etc.) I will abide by the decision made by the Best Interest attorney or privilege attorney regarding waiver of privilege of records. I Understand I Do Not Understand PROFESSIONAL RECORDS * You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in our electronic health record system and a protected electronic folder. This is your Clinical Record. Your Clinical Record 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, copies of assignments you or your child completes, email communications, 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, or during separation, or divorce, or custody proceedings, 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 am allowed to charge a copying fee (and certain other expenses). The exceptions to this policy are contained in the Notice of Privacy Practices Form. If we refuse your request for access to your Clinical Records, you have a right to review, which we will discuss with you upon request. I Understand I Do Not Understand CLIENT RIGHTS * HIPAA provides you with several rights regarding your Clinical Records and disclosures of protected health information (PHI). These rights include requesting restrictions on what information from your Clinical Records is disclosed to others; requesting an account of most disclosures of PHI that you have neither consent to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a copy of this Agreement, the Privacy Notice Form, and our privacy policies and procedures. I am happy to discuss any of these rights with you. I Understand I Do Not Understand SOCIAL MEDIA POLICY * Due to concerns about your confidentiality and psychologist/clinical social worker privacy, I have decided to decline friend or contact requests from current or former clients on personal social networking sites (Facebook, LinkedIn, etc.). Social Networking sites, such as Twitter, Facebook, and LinkedIn, are not secure. I do not respond to messaging or wall posting from clients on these sites. By posting on a public site, a clinician-client exchange may also need to be documented and become part of your clinical record. I make every attempt to protect your privacy. Additionally, cell phone communication, texts, and emails may not be secure because they might be viewable by a third party. It is between you and I as your therapist, as to the level of email, text, and cell phone contact to be incorporated in the treatment. I do not provide clinical advice via email. There are instances in which I find email/text messages to be convenient for both client and clinician. This includes communications such as appointment reminders, to cancel appointment, assignments, handouts, or for you or me to notify the other regarding an upcoming event or nonclinical issue. I have found that using email/text is a fast way of getting materials to you. However, please understand that email/text is not necessarily a secure medium. If you would like email/texts, such as appointment reminders, assignments, and handouts, please check the appropriate box below. Please know that if you provide me permission to communicate with you via email/text on matters such as appointment reminders, assignments, handouts, photographs of information (e.g., whiteboard plans) during individual sessions, as well as other information, the communications may include the name associated with the email address, as well as the name of the clinician, including credentials, as well as the name of our practice. I Understand I Do Not Understand I authorize the emails/texts discussed above. TELEHEALTH via VIDEO CONFERENCING * After intake and establishing a relationship, it may be determined -- due to convenience, distance, or other circumstances that make "in-person" treatment challenging -- that "face-to-face" or interactive video conferencing may be the preferred method of receiving treatment. Video conferencing (VC) is a real-time interactive audio and visual technology that allows for delivery of services via computer, phone, or another electronic device. The VC system I use (www.zoom.us) meets standards of encryption and privacy protection. You will not have to purchase a plan or provide your name when you "join" our meeting. Licensure regulations allow us to practice within the state that both client and clinician are located. I am approved by PSYPACT to practice teletherapy in Maryland and with client in states that are also PSYPACT approved. Regarding individual therapy via Zoom, please undertand that it is your responsibility to ensure that you and/or your child must be in a private space with no one else in the room to maintain confidentiality. A headset is recommended if there is a concern of voice(s) being heard from another room. I must have a phone number to reach you in case of need. Further inter-jurisdictional regulations still apply, and you must let me know your location. For ongoing telehealth, we require a signed Telehealth Agreement. I Understand I Do Not Understand AGREEMENT SIGNATURE PAGE * Your signature(s) below indicate(s) that you have read this agreement and agree to its terms and serves as an acknowledgement that you have been provided with a copy of the Notice of Policies and Practices to protect the Privacy of Client Health Information. Both parents must consent to the treatment of a minor. Type the Client's Name Below: First Name Last Name Electronic Signature of Client (or In case of minor, Parent/Guardian) * First Name Last Name Date * MM DD YYYY If Client is a Minor, Electronic Signature of Second Parent/Guardian First Name Last Name Date MM DD YYYY Email * Thank you! Your form has been submitted.
