NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
Each time we meet a record of your visit is made. This may include, but is not limited to, your symptoms, treatment interventions, diagnosis, test results, progress, your treatment plan, and billing-related information.
I am required by law to maintain the privacy of your protected health information (PHI) and provide you with a description of my privacy practices. I am committed to the terms of this notice.
HOW I MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
The following categories describe examples of the way I may use and disclose protected health information:
I may use your health information to coordinate treatment or services and/or continuity of care with other healthcare providers.
I may use and disclose your health information to bill and collect payment from you or a third party payor. I may also tell your health insurance plan about the treatment you are going to receive to determine your plan benefit coverage.
For Health Care Operations:
- To remind you that you have an appointment for medical care
- To tell you about health-related benefits or services
When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail.
We may communicate to you via forms, mail outs or other means regarding treatment options, billing issues, and health related information.
Law Enforcement/Legal Proceedings:
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of Tracy L. Helmer, Psy.D., you have the
Inspect and Copy:
You have the right to inspect and obtain a copy of the health information used to make decisions about your care. I may deny your request to inspect and/or receive a copy in certain circumstances. If you are denied access you may request that the denial be reviewed. Another independent, licensed health care professional hosen by Tracy L. Helmer, Psy.D. will review your request and the denial. I will comply with the outcome of the review.
If you feel that your health information is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for Tracy L. Helmer, Psy.D. I may deny your request for an amendment and if this occurs you will be notified of the reason for the denial.
An Accounting of Disclosures:
You have the right to request an accounting of disclosures. This pertains to disclosures I make of your health information for purposes other than treatment where an authorization was not required.
You have the right to request a restriction or limitation on the health information I use or disclose about you. You also have the right to request a limit on the health information I disclose about you to someone who is involved in your care or the payment for your care. I am not required to agree to your request. If I do agree, I will comply with your request unless the information is needed to provide emergency treatment.
Request Confidential Communications:
You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that I contact you at work instead of your home. I reserve the right to contact you by other means and at other locations if you fail to respond to any communication from me that requires a response. I will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.
A Paper Copy of This Notice:
You have the right to a paper copy of this notice. You may ask me to mail you a copy of this notice at any time.
CHANGES TO THIS NOTICE
I reserve the right to change this notice at any time.
If you believe your privacy rights have been violated, you may file a complaint with me. You may also file a complaint with the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to me will be made only with your written permission. If you provide me permission to disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, I will no longer disclose health information about you for the reasons covered by your written authorization. You understand that I am unable to take back any disclosures I have already made with your permission, and that I am required to retain my records of the care that I provided to you.
Your signature acknowledges that you have received this notice.
In case of emergency, who should be notified?
INFORMED CONSENT FOR TREATMENT
I value the patient-psychologist relationship and strive to keep all information confidential. I will only release information to others with your written permission.
There are some exceptions to this confidentiality. In accordance with state law, if I suspect that there is child abuse or neglect, abuse or neglect of an elderly or incapacitated adult, you are in immediate or imminent risk to self or others, I am legally obligated to report these concerns. I am also legally obligated to comply with a court order for a release of records. Furthermore, information may be required by the third-party payor and their agents for purposes of reimbursement.
There may be times when it would be helpful or necessary to consult with a colleague. If this occurs, I will make every effort to maintain onfidentiality of your identity. The consultant is, of course, also legally bound to confidentiality.
I am also required to provide your insurance company with relevant information to obtain reimbursement, including your diagnosis and treatment plan.
When seeing patients who are minors, please be aware that, while parents have legal access to their record, I ask all parents to respect the therapeutic relationship. While the specific content of each session is confidential, I am able to provide general information on treatment progress.
During your treatment, I will discuss your diagnosis, method of treatment, and treatment plan to help you reach your therapeutic goals. Take out the word me.
The nature of the treatment will be described to you along with any possible side effects and alternative forms of treatment.
You agree that you have read all intake forms and understand the scheduling policies, fees to be charged, and matters relating to insurance.
You authorize the treatment services deemed necessary by Tracy L. Helmer, PsyD. and authorize Dr. Helmer to release to your health plan any and all information which she deems necessary regarding your care and treatment to ensure prompt payment of all charges for services provided. You hereby assign the payment of all insurance benefits to Tracy L. Helmer, Psy.D. for any, and all charges incurred in connection with services provided to you. You also consent to a copy of this authorization and assignment being used in place of the original.
You understand fully that you remain responsible to pay Tracy L. Helmer, Psy.D. for all charges not paid by either your insurance company and/or employer, subject to the rules of any federal or state health insurance program such as Medicare or Medicaid, or to other contractual provisions that may limit a patient’s responsibility to pay for medical costs and services.
All monies due will be charged to the credit card that you have on file. Co-pays will be run on the credit card on file at the end of the business day. Any balances will be run at the end of the month.
A quote of benefits and/or authorization does not guarantee payment or verify eligibility. Payment of benefits are subject to all terms, conditions, limitations, and exclusions of the member’s contract at the time of service.
In consideration of the services rendered and to be rendered pursuant to my request for medical services from Tracy L. Helmer, Psy.D., you hereby waive any right to a jury trial should Tracy L. Helmer, Psy.D. have to file suit to collect on your account.
METHOD OF PAYMENT:
My office accepts all major credit cards. Each patient is required to complete the credit card information form. Should your credit card information change, the patient is responsible to complete and submit a new form to Dr. Helmer.
If fees are not paid, the patient understands that my office reports to an outside collection agency. In the event that your account is turned over for collections, the patient agrees to pay all additional fees accessed in the collection of the debt. These fees include collection agency fees and attorney fees. The parties agree that all claims, disputes and other matters of action shall be brought within and decided in the Commonwealth of Virginia.
You agree, in order for us to service your account or to collect any amounts you may owe, that
we may contact you by telephone at any telephone number associated with your account, including wireless telephone numbers, which could result in charges to you. We may also contact you by sending text messages or emails, using any email address you provide. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.
I/We have read this disclosure and agree that the Lender/Creditor may contact me/us as described above.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTOOD THIS INFORMATION AND GIVE CONSENT FOR TREATMENT
Welcome to my practice. My mission and goal is to help you create the life that you want by embracing healthy, loving, exciting, and fun behaviors while decreasing unhealthy and maladaptive behaviors and emotions. Here is important information that will address any questions and concerns.
All appointments will be held via a HIPAA compliant Telehealth platform. The initial appointment is the Diagnostic Assessment. During that time, I will collect all the necessary information to begin to develop your individualized treatment plan. This appointment lasts 50-55 minutes. All follow-up sessions are 45 minutes in length. Your appointment time is reserved exclusively for you. Should you need to cancel your appointment, please do so as soon as you are able. I do require a 48-hour notice for all cancelled appointments. Should you cancel in under 48 hours or simply fail to show up for your appointment your credit card will be charged a “late cancellation” or “no show” fee. I am committed to my work with you and want you to engage in the same level of commitment.
Diagnostic Assessment: $130.00
Individual Session: $110.00
Family Session: $110.00
Couples Session: $110.00
Late cancel/No Show Fee: $50.00
Payment is expected at the time of service. While my organization will verify your insurance benefits, please be aware that verification does not serve as a guarantee of coverage or payment. You are financially responsible for all charges. My billing service will file the insurance claims for you. All co-pays are required
to be paid at the time of service. I will bill the credit card that you have on file at the end of the business day. You are responsible to ensure that your credit card information is up to date.
In the event of an emergency, please reach out to me via text. You will be provided with my confidential cell phone number at our first session. Please be aware that I am not a 24-hour crisis line. If you are experiencing a crisis, please call Connect at 540.981.8181. If you are experiencing a life-threatening emergency, please call 911 or go directly to the emergency room.
As a professional, I strive to increase the cooperation, kindness and harmony in my patient’s lives. As such, I do not participate in the adversarial process. I ask all patients who participate in my treatment to agree that I will not be asked to participate in any court hearings. Should I be subpoenaed on ANY case that you
are affiliated with, I reserve the right to charge you $500.00 per hour. The time will start when I leave my office and end when I have returned to my office. A $5,000.00 pre-paid fee will be required prior to the court date and you agree to have this charged to your credit card on file. Any overpayment for the time not used will be immediately refunded to your credit card at the end of the day. Should the court appearance require additional hours your credit card will be charged those additional fees.
INTAKE INFORMATION FORM
CIGARETTE, ALCOHOL, AND DRUG USE
SYMPTON LIST (CHECK ALL THAT APPLY)
Informed Consent for Telehealth Services
This informed consent for Telehealth contains important information focusing on therapy by using the telephone or the Internet. Please read this carefully and let me know if you have any questions.This signed document represents an agreement between us.
There are benefits and risks of Telehealth. Telehealth provides psychotherapy services remotely using telecommunication technologies, such as videoconferencing or telephone. Telehealth benefits include easier access to care, no transportation or time costs, no need to take time off of work, no childcare expense, increased access, and a more efficient service delivery. Studies demonstrate the Telehealth is as effective, and sometimes more effective that traditional
therapeutic sessions in an office. Telehealth requires technical competence to be helpful.
Although there are benefits to Telehealth, there are some differences between in-person psychotherapy and Telehealth, as well as some risks. There is some risk to confidentiality because Telehealth sessions take place outside of the therapist’s private office. As your psychologist, I am committed to ensuring that your sessions are private and confidential from the provider perspective; however, there is the potential for other people to overhear sessions if you are not in a private place during the session. It is important for you to make sure you find a private place for your session where you will not be interrupted. It is also important for you to protect the
privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.
Should a crisis occur in our session, we agree that if I believe that there is a significant risk to your safety and well-being or that you pose a grave risk to someone else, I will utilize the emergency response team through 911 to maximize everyone’s safety.
For communication between sessions, I typically use text messaging, and sometimes email, with your permission. This tends to be for administrative purposes but, there are times that we may be texting to resolve a concern or question that you have. You should be aware that I cannot guarantee the confidentiality of any information communicated by emaill or text. Therefore, I will only discuss clinical information by email or text if you are requesting it. Also, I do not regularly
check my email or texts, nor do I respond immediately, so these methods should not be used if there is an emergency. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call or text within 24 hours except on weekends and holidays. If you are unable to reach me and feel you cannot wait for me to return your call, contact your family physician, psychiatrist, or the nearest emergency room.
Confidentiality, I have a legal and ethical responsibility to exert every effort to protect all communications that are a part of our Telehealth. However, the nature of electronic communication technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and backup systems when possible to help keep your information private, but there is a risk that communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications. For example, only use secure networks for Telehealth sessions and have passwords to protect the device you use for Telehealth. The extent of confidentiality and the exceptions to confidentiality that was described in the Informed Consent document still applies in Telehealth.
Please let me know if you have any questions about exceptions to confidentiality or the appropriateness of Telehealth.
If I decide that Telehealth is no longer the most appropriate form of treatment for you, we will discuss options of engaging in in-person therapy and I will provide you with a referral to other treatment providers in your location who can provide appropriate services. I will assist you in transitioning to another professional should that transition be indicated.
Emergencies and Technology
If the session is interrupted because of technology, and you are not having an emergency, please disconnect the session and I will wait 1-2 minutes and then re-contact you via the Telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within 2 minutes, then call me on the phone number I have provided you. If there is a technological failure and we are unable to resume the connection, you will only be charged a prorated amount of actual session time.
Assessing and evaluating threats and other emergencies can be more difficult when conducting Telehealth than in traditional psychotherapy. To address some of these difficulties, we will create an emergency plan before engaging Telehealth services. I have asked you to identify an emergency contact person who is near your location on the intake forms and I will contact that person in the event of a crisis or emergency to assist in addressing the situation. I ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such crisis or emergency. This authorization form is located at the end of this paperwork and MUST be completed as part of the intake packet. On the release you should put your emergency contact person’s name and telephone number and please check the box “emergency information”.
If the session is interrupted for any reason during an emergency, do not call me back; instead, call 911 or go to your nearest emergency room. Carilion Clinic has the Connect program (540.981.8181) for psychiatric emergencies. I ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.
The same fee rates will apply for Telehealth as apply for in person psychotherapy. However, insurance or other managed care providers may not cover sessions that are conducted via telecommunication. If your insurance, HMO, third-party payer, or other managed care provider does not cover electronic psychotherapy sessions, you will be solely responsible for the entire fee of the session. Please contact your insurance company prior to our engaging in Telehealth sessions in order to determine whether the sessions will be covered.
The Telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session in the same way I maintain records of in-person sessions.
This agreement is intended as a supplement to the general Informed Consent that we will agree to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions.
As part of my practice, I provide courtesy reminders of your appointment date and time. This form allows you to indicate how you would like to receive those
notifications. Please indicate if you are willing to accept reminders via email or text by indicating your email address or cell phone number and signing this form. If you would not like any email reminders, simply indicate your choice on the form.
I would prefer appointment reminders by: