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POLICIES

STATEMENT OF UNDERSTANDING

Welcome. This document describes my practice and the therapeutic relationship I establish with my clients. If any part is unclear, please feel free to ask for further explanation.

SERVICES PROVIDED

I offer assessment, clinical services, and appropriate follow-up. Cases that require involvement in the legal system including custody, court mandated treatment or disability cases are specialty areas that are not within the scope of my practice. As an individual practitioner, my ability to address crisis situations is very limited. Feel free to leave a message on my cell phone at any time 512-801-8353 and I will respond as soon as possible. In cases of medical or psychiatric emergency call 911 for life threatening situations.  In Austin, call 472-HELP (472-4357) for the City’s Hotline to Help, or 1-800-SUICIDE.

CONSENT FOR CARE

By signing this document you are giving full consent for Rebecca Davenport to evaluate and administer treatment in private practice.  By virtue of the nature of counseling, benefits and outcomes of treatment can not be guaranteed. Additionally, there are risks associated with psychotherapy including but not limited to: emotional discomfort, change in behaviors, and change in relationships.  There are a variety of competent practitioners and programs in the Austin area.  If you are in any way concerned regarding the course treatment or progress of your work in my practice, please let me know about your concerns.  My goal is to assist you in meeting your therapeutic goals, whether you work with me in my practice or through another community resource.

FEES & REIMBURSEMENT

There are generally 3 ways to compensate a clinician 1) through your company’s EAP where there is no out of pocket fee to you, 2) under your mental health insurance policy where you are responsible for a deductible and co-payments, 3) directly from you in a private pay capacity.  While filing insurance claims is a courtesy that may be extended to you, all charges are ultimately your responsibility.  All charges not covered by insurance are due at the time of services. I accept Visa and Master Card for your convenience.  Barring crisis situations, it is my policy to suspend sessions if a client or insurance company falls behind in payments more than 2 sessions.  If financial concerns become a barrier to treatment, please notify me immediately so that we can arrange for your continued care.

FEE SCHEDULE

• Individual, family, couple psychotherapy 50 min =  $90.00
• Seminar Presentation/hr minimum = $175.00
• Missed appointment (15 min grace period) = $60.00
• Group psychotherapy (75 min) = $50.00
• Scheduled Phone Consult  (30 min)  = $45.00
• Initial Session  = $110.00

CONFIDENTIALITY

The information you share in therapy is confidential. I will not release information without your written consent. There are legal exceptions and exclusions that effect confidentiality in therapeutic settings.  Please note the following: 1) third party payers (like your insurance company or EAP) require information regarding services you receive. In signing this document you give your consent to share information with a third party for the purpose of reimbursement. If you have concerns about information being shared with reimbursing agent, please discuss this issue with me. 2) In situations where there is a binding directive from a court of law, clinical records must be released in accordance with relevant law.  3)Safety. State and Federal laws stipulate that when a person is A) a danger to him or herself B) is a danger to others or C) has information regarding the abuse of a child or an elderly person, the clinician is required to report to the appropriate social service agency.  If reporting were necessary, my goal is to include you in the notification process.  Otherwise, if you request that I contact someone on your behalf you must sign an additional “informed consent for release” form.

COUNSELOR’S ROLE & CONSULTATION

The clinicians in the Hartland Plaza office are independent mental health practitioners who have come together to share certain expenses and administrative functions. No clinician is responsible or liable for the actions or opinions of any other clinician. As your clinician I am responsible to assist you in defining and working toward therapeutic goals. This process includes an assessment of your current situation and review of pertinent historic information. Goals and progress will be reviewed periodically over the course of treatment. To facilitate quality clinical services, I may engage in clinical consultation/supervision with another licensed professional in a manner that maintains your anonymity. In addition, and with client’s written consent, I occasionally present cases to a peer supervisory board the outcome of which can shared with the client system.

CLIENT’S ROLE

Ultimately, you are responsible for the decisions you make, including those that effect your course of care and services your receive. You are responsible for setting and keeping appointments. It’s important that you provide as much notice as possible if you must miss a scheduled appointment.  If you do not attend a scheduled appointment or cancel with less than 24 hours notice, you will be charged for the missed appointment.  You have the right to ask for a referral out of my practice and/or terminate treatment with me at anytime.

PRIVACY STATEMENT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.

For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization. We may use your PHI to remind you of appointments, to contact you regarding services you receive and to notify you of services available to you. Please be sure to specify contact parameters and information on your client information form to facilitate operations activities.

Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.

Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:

– Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department)
– Required by Court Order
– Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it
– will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission
We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer R. Davenport at 1717 W. 6th St. #345, Austin, Tx. 78703 or 512-801-8353.

• Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
• Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
• Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.Right to a Copy of this Notice. You have the right to a copy of this notice.

COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at R. Davenport at 1717 W. 6th St. #345, Austin, Tx. 78703 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint. The effective date of this Notice is April 14, 2003.

Based on Document by NATIONAL ASSOCIATION OF SOCIAL WORKERS
© Popovits & Robinson, P.C. 2003