Couple and family sessions may last up to 75 minutes. There is always a 10-minute break between sessions allowing the psychologist to write notes and to prepare for the next client. Once an appointment for a session is scheduled, you will be expected to pay for the session unless you provide 48 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for cancelled sessions. The full session fee will be automatically charged for missed sessions without such notification and is considered an out-of-pocket expense. Reasonable attempts shall be made to reschedule appointments, if given within 48-hours, or greater, notice.
The fee for an initial psychiatric consultation is $280.00. The for any subsequent sessions $250.00. The fees are due at the time of the session. In addition to weekly appointments, I charge $250.00 per hour for other professional services you may need, although I will break down the hourly cost if I work for period less than one hour. I will attempt to return calls and e-mails in a reasonably prompt manner and will charge at the percentage of time used (at the normal session rate) if any telephone calls, reading and/or answering of e-mails requires more than 10 minutes time, after which time the full amount of time expended will be charged and billed for. This is to encourage issues be discussed within the therapeutic session and framework unless of a critical manner that needs immediate and brief attention; in this circumstance a sooner session may be mutually arranged and agreed upon. Other services that I can provide that will be charged at my hourly rate include report writing, consulting with another professional with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me.
If you become involved any legal proceedings that require my participation, you will be expected to pay for all of my professional time, including preparation and transportation costs, or any interactions relating to your case, even if I am called to testify by another party. As my involvement in any legal proceedings is burdensome, I charge a non-negotiable fee $550.00 per hour for preparation, attendance at any legal proceeding, including my services as a "fact witness". Goss and Associates requires a 4 hour minimum retainer ($2200). Expedite fees will apply for urgent needs depending on circumstances and timeframe. Expedite fees applies for less than 2 weeks notice, during holidays, or without typical lead in time usually are between 1.5 to 2 times the normal customary legal proceedings rate.
Due to my work schedule, I am often not immediately available by telephone. It may take a day or two for non-urgent matters. When I am unavailable, my telephone is answered by confidential voice mail. If you are unable to reach me and feel that you can't wait for me to return your call, contact your nearest emergency room and ask for the psychologist (psychiatrist) on call.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a client and a psychologist. In most situations, I 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: I may occasionally 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 identity of my client. The other professionals with whom I consult are also legally bound to keep the information confidential. If you don't object, I will not tell you about these consultations unless I feel that it is important to our work together. I will note all consultations in your Clinical Record (which is called "PHI" in my Notice of Psychologist's Policies and Practices to Protect the Privacy of Your Health Information). While in Couples therapy, please be aware that the psychologist will not take sides, and has a No Secrets Policy. That means that Client should have no expectation that Therapist will treat extra-therapeutic conversations with Couples and/or Family therapy participants as confidential between other members of the group. It is preferable" for secrets not to pollute the therapeutic process and the psychologist reserves the right to disclose any secrets to other members if the psychologist feels it beneficial, necessary or appropriate. I also have contracts with an accountant, a billing service, and an attorney. As required by HIPAA, I have a formal business associate contract with these businesses, in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If a client threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection. There are some situations where I am permitted or reguired to disclose information without either your consent or Authorization:
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 psychologist-patient privilege law. I cannot provide any information without your (or your legal representative's) written authorization, or court order, or if a subpoena is served on me with appropriate notices, I may have to release information in a sealed envelope to the clerk of the court issuing the subpoena. 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 information. Other situations of which I may be required to provide information may health oversight activities by a government agency, if a client files a complaint or lawsuit against me, and/or if a client files a worker's compensation claim, I may disclose relevant information.
There are some situations in which I am legally obligated to take actions, 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 suspect that a child is abused or neglected, an adult is abused, neglected or exploited, if a client communicates a specific threat of immediate serious physical harm to an identifiable victim, and I believe he/she has the intent and ability to carry out the threat, I am required to take protective actions. These actions may include notifying the potential victim or his/her guardian, contacting the police or social services, or seeking hospitalization for 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 my disclosure to what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now 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, I may need to seek formal legal advice.
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It 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, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself, 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. The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request.
In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that such disclosure would be injurious to your health or well-being.
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.
MINORS & PARENTS
Children of any age have the right to independently consent to and receive mental health treatment without parental consent and, in that situation, information about that treatment cannot be disclosed to anyone without the child's agreement. 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.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held. In circumstances of, unusual financial hardship, which is in my sole discretion, I may be willing to negotiate a fee adjustment or payment installment plan.
There is a $50.00 charge for each returned check. This charge will be automatically billed to you. I also accept certain credit and debit cards for purposes of payment of your account balance. Once you provide me with your credit card number, expiration date and verification code for purposes of making a payment on your account, I will utilize this same information to pay your outstanding account balance, without additional authorization or approval from you, if your account is not paid within 60 days. You must provide me written notice that my authorization to pay your account with your credit card is withdrawn. There is a $40.00 administration fee, $40.00 late fee charge on outstanding balances, and possible $40.00 collection agency processing fees applied monthly.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I may pursue whatever legal means are necessary to secure collection of your outstanding balance. This may involve hiring a collection agency, retaining an attorney, or going through small claims court which will requirement to disclose otherwise confidential information.
In most collection situations, the only information I release regarding a client's treatment is his/her name, the nature of services provided, and the amount due. Please note the client/undersigned is responsible for costs and attorney fees of 35% of the outstanding if this account is sent to collections/and or an attorney, as well as interest at the rate of 18% per annum on all overdue balances.
I am in the Blue Cross Blue Shield PPO provider network for individuals. I do particiapate in the Federal Government's BCBS tradtional plan--beginning with subscriber/member ID code "R". With the exception of Blue Cross/Blue Shield insurance, I do not accept insurance for payment (including the current Blue Cross Blue Shield Blue Choice, the newest 2018/2019 Federal Goverments' Blue Choice Plan or plans with subscriber/member ID code "X", Anthem BCBS' EAP, and other HMO products). In the event of an individual session occurring for an extenuating situation or crises while working with a couple, I will be happy to assist by providing you a receipt for submission or reimbursement purposes. You should be aware that marital and relationship therapy is considered a dis-allowable and is not a reimbursable service. You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis and brief substantiation of that diagnosis. This information is limited to the dates of treatment and a brief description of the services provided, including the type of therapy provided. This information will become part of the insurance company files and will probably be stored in a computer. 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. By signing this Agreement, you agree and authorize that I can provide to your insurance carrier, upon request, information or documentation regarding the professional services I have provided to you.
SNOW/INCLEMENT WEATHER POLICY
During inclement weather or if in doubt, it is advisable to call and check with the psychologist before coming in. Clients are typically not charged for appointments canceled because of weather. Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
RIGHT TO COPY THIS NOTICE
Clients have the right to an e-mail or pdf copy of this signed notice (as thee office is paperless). Client may ask for a copy of this notice at any time. Therapist has the right to change or update this Agreement at any time and to provide you a new copy to sign with mutual agreement to in order to continue treatment.
Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE.