CONSENT TO TREATMENT
A "therapist-patient" or "treatment" relationship does not exist until after initial assessment is completed and we have decided to move ahead as evidenced by your signature on this form. It is important that we both agree that we are a good match in working together towards your goals. We will discuss this during the first visit and decide whether or not to proceed, and whether we need to continue the assessment for one or more subsequent visits. It is also important for you to be aware of the benefits and limitations of psychotherapy or other services you will be receiving. While it is generally expected that you will benefit from therapy, there may be periods of feeling worse before feeling better and there is no guarantee of success in therapy. There may be alternative treatments or modes of therapy to consider. I encourage you to become aware of these factors and to ask any questions you may have at any time during our work together.

CONFIDENTIALITY
State law protects the confidential nature of the therapist-patient relationship but this protection is not absolute. I will not release clinical information to anyone unless given written permission to do so by the patient (or if the patient is a minor, by his or her parent or guardian). However, there are a few exceptions that allow or require the release of confidential information even in the absence of patient consent.
Examples Include:

1) The therapist must act appropriately when there is danger to the patient or to another person at the patients hands. This generally means that the therapist may involve others when necessary to protect the patient if he or she is suicidal or is unable to provide self-care at a level necessary for basic survival, or to prevent harm to another person. State law also requires the reporting of abuse to or neglect of a child or an elderly or disabled person when there is reason to believe it has occurred.

2) In response to a court order, the therapist must testify or release records. However, a therapist does not release records, depose or testify in response to a subpoena unless the patient or patient's guardian has given written authorization to do so or if the therapist is required by law to do so.

3) As professionals, we do consult with one another from time to time. Any clinical material is conveyed without identification whenever possible. At other times, it will be necessary (for example, if another therapist is covering calls during a vacation). Finally, case material is sometimes used in training, research, writing, etc. This is always done with identifying information removed and with great care and respect for your privacy. Any other release of information requires you or your guardian's written authorization.

OFFICE & FINANCIAL POLICIES
Fees: Payments are due at the time services are rendered; payments will be received at the beginning of each session. It is up to the discretion of the therapist to allow for a deferred payment.

Insurance: I will be glad to file in-network claims. However, you will be responsible for the full fee/co-payment/co-insurance at the time of service unless we make other arrangements. You will also be responsible for charges not covered by your Insurance Company or any amount determined to be your responsibility by your Insurance Company.

Information regarding out-of-network payments is available and we will work to help answer any questions you may have regarding reimbursement through your insurance carrier and/or provide necessary documentation for filing insurance claims. The therapist may bill excessive insurance paperwork demands separately after consultation with the patient. Generally routine notes or other documentation will not be considered excessive.

EMERGENCIES: I DO NOT PROVIDE FORMAL EMERGENCY SERVICES, YET I WISH TO BE AS AVAILABLE AS MUCH AS IS REASONABLY POSSIBLE. YOU MAY CALL THE OFFICE NUMBER AT ANY TIME AND LEAVE A MESSAGE IF I DO NOT ANSWER. DURING THE BUSINESS DAY I CAN OFTEN, THOUGH NOT ALWAYS, RETURN CALLS FAIRLY QUICKLY. NIGHTTIME AND WEEKEND CALLS WILL USUALLY BE RETURNED THE NEXT BUSINESS DAY. IF YOU FIND YOURSELF IN AN URGENT SITUATION, MAKE A JUDGMENT ABOUT THE PRUDENCE OF WAITING FOR MY CALL VERSUS CALLING 911 OR GOING TO THE NEAREST EMERGENCY ROOM FOR IMMEDIATE CARE. IF I AM AWAY FOR MORE THAN A DAY, MY VOICE MAIL MESSAGE WILL INDICATE THAT AND STATE MY EXPECTED DATE OF RETURN.

Death or Incapacity: In the event that the therapist dies or is otherwise incapable of providing for the clinical services of this office the patient consents for the therapist to designate a conservator for the records of this office, including all patient records, and at the time of death or incapacity of the therapist the conservator will take possession of the patient records and make those available to the patient or a mental health professional of the patient's choosing at such time that a written request is made to this office.

Complaints: I strive to always provide competent and professional services to our patients. From time to time there may be an issue that we need to address. Please notify the office immediately of any problems or complaints and we will work with you to solve these together. If we are unable to reach a satisfactory solution you can direct inquiries to:  

Texas Behavioral Health Executive Council

Attn: Enforcement Division

333 Guadalupe St., Ste. 3-900

Austin, Texas 78701

Enforcement@bhec.texas.gov

Other fees: If report preparation is requested or required, the time rate charged for our therapy sessions will apply. Extended or frequent telephone contact will also be charged for. These services are not usually reimbursed by insurance.  I DO NOT PARTICIPATE IN HIGH CONFLICT CASES AND/OR PROVIDE FORENSIC SERVICES AND WILL NOT AGREE TO COURT APPEARANCES OR OTHER LEAGAL INVOLVEMENTS. 

Accounts: Payment may be made with cash, credit card, or by check. Credit Card payments are processed through Square. I do not extend credit. In any such arrangement, late payment fees of $10 per month will be charged on any balance not paid within 30 days. I do not depend on an outside collection service unless accounts are overdue by 90 days. I would much rather communicate with patients and find some solution to overdue accounts. Patient hereby consents to the delegation of collection activities to an outside collection agency, including the release of necessary information required by the collection agency. A delinquency fee of 40% of the outstanding balance will be added if a collection agency is required. There is a returned check-processing fee of $25 in addition to reimbursement for charges assessed by my bank. Statements, receipts, or other documentation will not be issued to any delinquent account until paid in full.

MISSED APPOINTMENTS: UNLESS WAIVED BY MUTUAL AGREEMENT ON A CASE-BY-CASE BASIS, NO-SHOWS AND CANCELLATIONS WILL BE CHARGED FOR UNLESS YOU CANCEL AT LEAST 24 HOURS IN ADVANCE OF THE APPOINTMENT TIME.

PATIENTS ARRIVING 15 MINUTES OR MORE LATE TO THE APPOINTMENT WILL BE CONSIDERED A NO-SHOW AND MUST BE RESCHEDULED UNLESS OTHER ARRANGEMENTS ARE MADE WITH THE THERAPIST.

THE FEE FOR LATE CANCELLATIONS, (LESS THAN 24 HOURS NOTICE) AND NO-SHOWS IS 100% OF THE FULL SESSION FEE. 

AUTHORIZATION IS GIVEN, WHERE APPLICABLE, TO CHARGE CREDIT/DEBIT CARDS FOR LATE OR NO-SHOW APPOINTMENT FEES WHEN INCURRED. PATIENT UNDERSTANDS THE APPOINTMENT POLICIES OF THE OFFICE AND ASSUMES RESPONSIBILITY FOR PAYMENT OF FEES RELATED TO LATE CANCELLATIONS OR NO-SHOW APPOINTMENTS. SUCH CHARGES ARE PAYABLE IMMEDIATELY AND WILL BE AUTOMATICALLY DEDUCTED, WHERE APPLICABLE, AND ARE NOT NORMALLY REIMBURSABLE BY INSURANCE.

It is the policy of this office that:

1. All clinical records are protected from public viewing and access.

2. All clinical records are in individual file folders, identified by patient name and #.

3. All clinical records are kept under lock and key.

4. Computer patient records may only be accessed with a password known to the therapist and authorized office personnel. Any backup files are kept in a locked filing cabinet.

5. Only office personnel authorized to access clinical records are given access to files.

6. Client information will not be shared without the written consent of the client, except as required by law, or in a situation determined to be potentially life threatening.

7. All office personnel have been trained on and will follow the above guidelines.

8. Any privacy guideline not followed by office personnel will be documented and appropriate disciplinary action will take place.

9. Patients may file a formal complaint regarding compliance with the privacy rule or policies and procedures related to the rule. Written patient complaints will be logged and filed.

10. All faxes originating from this office that contains PHI will include a cover sheet indicating to whom the information should be received as well as a disclaimer requiring the return of the information if received by the wrong party. A confidentiality notice will also be on the fax.

11. Any electronic PHI sent from this office will only be sent for claim payment or for approval of additional services from the patient’s insurance company.

12. Confidentiality procedures and Patients Rights regarding their records will be given to each patient.

I hereby assign, transfer and set over to MKM Counseling Services, Inc. (Monica Marterella, MS, LMFT-S, LPC-S), all of my rights, title and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine benefits, payment, concurrent review, and quality assurance activities, including medical, surgical, psychiatric and/or substance abuse (drug or alcohol) information. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that this order does not relieve me of my obligation to pay such bills if not paid by my Insurance Company, or of any balance due after payments by my Insurance Company.

I have received and understand this practice's Notice of Privacy Practices written in plain language. The notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, and the practice's legal duties with respect to my protected health information (hereafter called PHI). This includes but is not limited to:

• A statement that this practice is required by law to maintain the privacy of PHI.
• A statement that this practice is required to abide by the terms of the notice currently in effect.
• Types and uses of disclosures that this practice is permitted to make for each of the following purposes: treatment, payment, and health care operations.
• A description of each of the other purposes for which this practice is permitted or required to use or disclose PHI without my written consent or authorization.
• A description of uses and disclosures that are prohibited or materially limited by law.
• A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
• My individual rights with respect to PHI and a brief description of how I may exercise these rights in relation to:

• The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
• The right to request restrictions on certain uses and disclosures of my PHI, and that this practice is not required to agree to a requested restriction.
• The right to receive confidential communications of PHI.
• The right to inspect and copy PHI.
• The right to amend PHI.
• The right to receive an accounting of disclosures of PHI.
• The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all PHI that it maintains. If changes occur, this practice will provide me a revised Notice of Privacy Practices on request.