HAMBURG COUNSELING SERVICE, INC.
97 South Buffalo Street
Hamburg, NY 14075
Phone: (716) 648-0650
Fax: (716) 648-0666
A Community Mental Health Program
Serving Residents of the Southtowns of Western
New York
Hamburg Counseling Service
SERVICE AGREEMENT
Welcome to the Mental
Health Clinic at Hamburg Counseling . This document contains important
information about our 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 patient rights with regard to the use and disclosure
of your health information used for the purpose of treatment, payment,
and health care operations. Your therapist can discuss any questions
you have about your privacy. When you sign this document, it will
also represent an agreement between us. You may revoke this Agreement
in writing at any time
CLINICAL SERVICES
The services we provide
will address the particular problems you are experiencing. There are
many different methods we may use to deal with these problems. 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.
If you see our psychiatrist, there are risks (e.g. side effects) and
benefits to medications he may prescribe.
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,
we 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 your therapist.
If you have questions about your therapist’s procedures, please
discuss them whenever they arise. If your doubts persist, we will
be willing to help you set up a meeting with another mental health
professional for a second opinion.
MEETINGS
Your therapist will
normally conduct an evaluation that will last from 1 to 3 sessions. If psychotherapy is begun, your therapist will
usually schedule one 50-minute session (one appointment hour of 50
minutes duration). Once an appointment hour is scheduled, you will
be expected to pay for it unless you provide 24 hours advance
notice of cancellation [unless we agree that you were unable to
attend due to circumstances beyond your control]. It is important
to note that insurance companies do not provide reimbursement for
cancelled sessions.
PROFESSIONAL FEES
Hourly fees range from $60-$85 depending on which staff
you see. This maybe covered
by insurance. If you become involved in legal proceedings that require
our participation, you will be expected to pay for all of our professional
time, including preparation and transportation costs, even if your
therapist is called to testify by another party
CONTACTING US
While your therapist
is usually in the office between 9 AM and 5 PM, he or she probably
will not answer the phone when with other clients.
Your therapist will make an effort to return your call on the
same day you make it, with the exception of weekends and holidays.
If you are unable to reach your counselor, and feel that you
can’t wait for a return call, contact your family physician or Crisis
Services at 834-3131
LIMITS ON CONFIDENTIALITY
The NY State law protects
the privacy of all communications between a client and this clinic.
In most situations, we can only release information about your treatment
to others if you sign a written Authorization form that meets certain
legal requirements imposed by HIPAA. There are other situations that
require only that you provide written, advance consent. Your signature
on this Agreement provides consent for those activities, as follows:
·
Supervision
with mental health professionals within this clinic. In most cases,
protected information is shared with administrative staff for purposes,
such as scheduling, billing and quality assurance. All of the mental
health professionals are bound by the same rules of confidentiality.
·
Disclosures
required by health insurers or to collect overdue fees are discussed
elsewhere in this Agreement.
·
If a
patient threatens to harm himself/herself, we may be obligated to
seek hospitalization for him/her, or to contact family members or
others who can help provide protection.
·
If you
are involved in a court proceeding, we cannot provide any information
without your written authorization, or a court order.
·
If a
government agency is requesting the information for health oversight
activities, we may be required to provide it for them.
·
If you
have a worker’s compensation claim, we may have to submit such records,
upon appropriate request, to Chairman of the Worker’s Compensation
Board.
·
If there
is suspicion of child abuse or neglect, the law requires us to report
to NYS Child Protective Services.
·
If there
is immediate threat of serious physical harm to an identifiable victim,
I may be required to take protective actions. These actions may include
notifying the potential victim, contacting the police or Crisis Services.
If such a situation
arises, we will make every effort to fully discuss it with you before
taking any action and we will limit our disclosure to what is minimally
necessary.
The laws governing
confidentiality can be quite complex, and we are not qualified to
give legal advice. In situations where specific advice is required,
formal legal advice may be needed.
PROFESSIONAL RECORDS
The law requires that
we keep Protected Health Information about you in your Clinical Record.
You may have access to your record, if you request it in writing.
Access may be denied in unusual circumstances that involve danger
to you and/or others or where others have supplied information confidentially.
If we refuse your request for access to your records, you have
a right to review, which your
therapist will discuss with you upon request.
CLIENT’S RIGHTS
HIPAA provides you
with rights with regard to your Clinical Records and disclosures of
protected health information. You may amend your record; request restrictions
on what information from your Clinical Records is disclosed to others;
request an accounting of most disclosures of protected health information;
having any complaints you make about our policies and procedures recorded
in your records; and the right to a paper copy of this Agreement,
the attached Notice form, and our privacy policies and procedures.
You also have the
right to:
- an individual treatment plan
- to be able
to object to a treatment plan
- Treatment appropriate to your cultural background
- To non-discrimination
- to freedom from abuse & mistreatment
- to clinically appropriate care
- to an explanation of services in accordance to your
service plan
- to participate voluntarily in and consent to treatment
BILLING AND PAYMENTS
You will be expected
to pay for each session at the time it is held unless you have insurance
coverage that requires another arrangement. You will receive a receipt
for each payment.
If no such coverage
is available, you are charged a fee based on your income. The remainder of the fee is subsidized by funding
from New York State and the Towns of
Hamburg and Eden .
If your account has
not been paid for more than 60 days and arrangements for payment have
not been agreed upon, Hamburg Counseling Service has the option of
using legal means to secure the payment. This may involve hiring a
collection agency or going through small claims court, which could
require disclosure of confidential information. In most collection
situations, the only information we release is a client’s 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
We will provide you
with whatever assistance in helping you receive the benefits to which
you are entitled; however, you (not your insurance company) are responsible
for full payment of fees. It is very important that you find out exactly
what mental health services your insurance policy covers
Please bring any change
in health insurance coverage to the attention of the office staff
as soon as possible so that your fee can be adjusted accordingly
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 HMOs and 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 are exhausted.
Some managed-care plans will not allow services to you once your benefits
end. If this is the case, we will not deny you of services but the
fees may change according to your income.
Your health insurance company requires that we
provide it with information relevant to our services. They require
us to provide a clinical diagnosis and sometimes we are required to
provide additional clinical information such as treatment plans or
summaries, or copies of your entire Clinical Record. In such situations,
we will make every effort to release only the minimum information
about you that is necessary for the purpose requested.
By signing this Agreement, you agree that we can provide requested
information to your carrier.
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signature date