THIS NOTICE DESCRIBES HOW MEDICAL (INCLUDING MENTAL HEALTH) INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I. USES AND DISCLOSURES OF PROTECTED INFORMATION
A. General Uses and Disclosures Not Requiring the Client’s Consent. The provider will use and disclose protected health information in following ways.
1. Treatment. Treatment refers to the provision, coordination, or management of health care (including mental health care) and related services by one or more health care providers. For example, the provider will use your information to plan your course of treatment. As to other examples, the provider may consult with professional colleagues or ask professional colleagues to cover calls of the practices or the provider and will provide the information necessary to complete those tasks.
2. Payment. Payment refers to the activities undertaken by a health care provider (including a mental health provider) to obtain or provide reimbursement for the provision of health care. The provider will use your information to develop accounts receivable information, bill you, and with your consent, provide information to your insurance company or other third-party payer for services provided. The information provided to insurers and other third-party payers may include information that identifies you, as well as your diagnosis, type of services, provider name/identifier, and other information about your condition and treatment. If you are covered by Medicare, information will be provided to the State of Colorado’s Medicare program, including but not limited to your treatment, condition, diagnosis, and services received.
3. Health Care Operations. Health Care Operations refer to activities undertaken by the provider that are regular functions of management and administrative activities of the practice. For example, the provider may use or disclose your health information in the monitoring of service quality, staff evaluation, and obtaining legal services.
4. Contacting the Client. The provider may contact you to remind you of appointments and to tell you about treatments or other services that might be of benefit to you.
5. Required by Law. The provider will disclose protected health information when required by law or necessary for health care oversight. This includes, but is not limited to: (a) reporting child abuse or neglect, including any past or present sexual contact with a minor; elder abuse or neglect; domestic violence (b) when court ordered to release information (c) when there is a legal duty to warn or take action regarding in imminent danger to others; (d) when the client is a danger to self or others or gravely disabled; (e) when a coroner is investigating the client’s death; or (f) to health oversight agencies for oversight activities authorized by law and necessary for the oversight of the health care system, government health care benefit programs, or regulatory compliance.
6. Crimes on the premises or observed by the provider. Crimes that are observed by the provider or the provider’s staff, crimes that are directed towards the provider or the provider’s staff, or crimes that occur on the premises will be reported to law enforcement.
7. Business Associates. Some of the functions of the provider may be provided by contracts with business associates. For example, some of the billing, legal, auditing, and practice management services may be provided by contracting with outside entities to perform those services. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. Business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
8. Research. The provider may use or disclose protected health information for research purposes if the relevant limitations of the Federal HIPAA Privacy Regulations are followed. 45 CFR § 164.512(i).
9. Involuntary Clients. Information regarding clients who are being treated involuntarily, pursuant to law, will be shared with other treatment providers, legal entities, third party payers and others, as necessary to provide the care and management coordination needed.
10. Family Members. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.
11. Emergencies. In life threatening emergencies the provider will disclose information necessary to avoid serious harm or death.
B. Client Authorization or Releases of Information. The provider may not use or disclose protected health information in any other way without a signed authorization or release of information. When you sign an authorization, or a release of information, it may later be revoked, provided that the revocation is in writing. The revocation will apply, except to the extent the provider has already taken action in reliance thereon.
C. Disposal of personal identifying documents to protect patient privacy. Please notes, unless otherwise required by federal law or regulation, when paper or electronic documents that contain "personal identifying information” are no longer needed, these documents will be destroyed or destruction of such paper and electronic documents will be arranged. Such documents within Dr. Phillips’ custody or control that contain personal identifying information will be destroyed by shredding, erasing, or otherwise modifying the personal identifying information in the paper or electronic documents to make the personal identifying information unreadable or indecipherable through any means.
II. YOUR RIGHTS AS A CLIENT A. Access to Protected Health Information. You have the right to inspect and obtain a copy of the protected health information the provider has regarding you, in the designated record set. However, you do not have the right to inspect or obtain a copy of psychotherapy notes. There are other limitations to this right, which will be provided to you at the time of your request, if any such limitation applies. To make a request, ask your therapist.
B. Amendment of Your Record. You have the right to request that the provider amend your protected health information. The provider is not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, if relevant, along with the appeal process available to you. To make a request, ask your therapist.
C. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures the provider has made regarding your protected health information. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations. In addition, the accounting does not include disclosures made to you, disclosures made pursuant to a sign Authorization, or disclosures made prior to April 14, 2003. There are other exceptions that will be provided to you, should you request an accounting. To make a request, ask your therapist.
D. Additional Restrictions. You have the right to request additional restrictions on the use or disclosure of your health information. The provider does not have to agree to that request, and there are certain limits to any restriction, which will be provided to you at the time of your request. To make a request, ask your therapist.
E. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information from the provider by alternative means or at alternative locations. For example, if you do not want the provider to mail bills or other materials to your home, you can request that this information be sent to another address. There are limitations to the granting of such requests, which will be provided to you at the time of the request process. To make a request, ask your therapist.
F. Copy of this Notice. You have a right to obtain another copy of this Notice upon request.
III. Fees and Payments A. Fee Rate: The charge for each therapy meeting will be at the rate of $125 per follow up session and $155 for each intake session or at the rate agreed upon your insurance if you have been preapproved for mental health treatment through these carriers. Additional fees will be arranged if you should require me to spend an unusual amount of time on auxiliary services such as consultation with other professionals, preparation for testimony or telephone calls over five minutes. These services will be charged at the standard rate. Fees for psychological testing are based on time with the patient plus time required for scoring and interpreting test data. For sessions conducted anywhere other than the office, travel time plus expenses will be charged at the standard fee.
B. Payment Method: Payment is requested at the time of services unless we agree otherwise or unless you have insurance coverage which requires another arrangement. In these situations, co-payments and non-allowable charges are requested at the time of service. Payment may be made by check, cash, or most major credit cards.
C. Statements: If psychotherapy/consultation is scheduled on a regular and ongoing basis, clients may request monthly statements/payments. When monthly statements are rendered, payment is expected within 10 days of receipt of statement.
D. Past Due Accounts: Processing past due accounts is expensive (supply costs, postage, bookkeeping services, etc.) A $25 rebilling charge will be added to all accounts with overdue balances (unpaid charges older than 60 days) unless other arrangements have been made. All overdue accounts (unpaid after 60 days) will be submitted to a collection agency. If such action is necessary, its costs will be included in the claim. In most collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.
III. ADDITIONAL INFORMATION A. Privacy Laws. The provider is required by State and Federal law to maintain the privacy of protected health information. In addition, the provider is required by law to provide clients with notice of the provider’s legal duties and privacy practices with respect to protected health information. That is the purpose of this Notice.
B. Terms of the Notice and Changes to the Notice. The provider is required to abide by the terms of this Notices, or any amended Notice that may follow. The provider reserves the right to change the terms of its Notice and to make the new Notice provisions effective for all protected health information that it maintains. When the Notice is revised, the revised Notice will be posted at the provider’s service delivery sites and will be available upon request.
C. Complaints Regarding Privacy Rights. If you believe the provider has violated your privacy rights, you have the right to complain to the provider. Your therapist is the person designated within the practice to receive your complaints. You also have the right to complain to the United States Secretary of Health and Human Services by sending your complaint to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 515F, HHH Bldg., Washington D.C. 20201. It is the policy of the provider that there will be no retaliation for your filing of such complaints.
D. The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Section of the Division of Registrations. The Board of Psychologist Examiners can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800.
E. Additional Information. If you desire additional information about your privacy rights, ask your therapist.
F. Effective Date. This Notice is effective January 1, 2019.
G. The following is also required by the state of Colorado: (I) A client is entitled to receive information about the methods of therapy, the techniques used, the duration of therapy, if known, and the fee structure; (II) The client may seek a second opinion from another therapist or may terminate therapy at any time; (III) In a professional relationship, sexual intimacy is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant, or certificate holder; (IV) The information provided by the client during therapy sessions is legally confidential in the case of licensed marriage and family therapists, social workers, professional counselors, and psychologists; licensed or certified addiction counselors; and registered psychotherapists, except as provided in section 12-43-218 and except for certain legal exceptions that will be identified by the licensee, registrant, or certificate holder should any such situation arise during therapy; and (e) If the mental health professional is a registered psychotherapist, a statement indicating that a registered psychotherapist is a psychotherapist listed in the state's database and is authorized by law to practice psychotherapy in Colorado but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain a registration from the state. (2) If the client is a child who is consenting to mental health services pursuant to section 27-65-103, C.R.S., disclosure shall be made to the child. If the client is a child whose parent or legal guardian is consenting to mental health services, disclosure shall be made to the parent or legal guardian.
H. Surprise/Balance Billing Disclosure Form
Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:
You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or
You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado
What is surprise/balance billing, and when does it happen?
If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.
When you CANNOT be balance-billed:
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.
Non-emergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.
You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.
Your insurer will pay out-of-network providers and facilities directly.
Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.
If you receive services from an out-of-network provider or facility or agency or OTHER situations, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive non-emergency services from an out-of-network provider or facility, you may also be balance billed.
If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.
*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.
Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.
I. Generally speaking, the information provided by and to you as the client during the therapy sessions is legally confidential. Since the information is legally confidential, I cannot be forced to disclose any of your information without your consent. Information disclosed to me is privileged communication and cannot be disclosed in any court of competent jurisdiction in the State of Colorado without the consent of the person to whom the testimony sought relates.
If I am ever in a position where I am asked/directed/etc. to resist disclosure in a legal services/proceedings/etc. context (resist revealing what is in your mental health records, contents of conversations, etc.), you, the client/patient, will be responsible for all associated legal fees.
I. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information.
J. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate and should be reported to the board that licenses, registers, or certifies the licensee, registrant or certificate holder.
K. You can seek a second opinion from another therapist or terminate therapy at any time.