THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU

CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The Health Insurance Portability and Accountability Act of 1996 ("HIPPA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us, in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we many use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: Treatment, payment, and health care operations.

- Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a counseling session.

- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

- Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:

- The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

- The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

- The right to inspect and copy your protected health information.

- The right to amend your protected health information.

- The right to receive an accounting of disclosures of protected health information.

- The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of March 23, 2009 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information or to file a complaint: The U.S. Department of Health and Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201

(202) 619-0257

Toll-free: 1-877-696-6775

Goals and Outcomes: Thank you for choosing New Hope Counseling for your care and I look forward to helping you meet your goals. Your goals are more likely to be met when you understand the nature and limitations of counseling. Generally, counseling is most useful in helping individuals help themselves or improve their relationships by changing, feelings, thoughts, and /or behaviors. You determine the nature and amount of change you wish to make. 

Benefits and Risks Most people experience improvement or resolution to the concerns that brought them to counseling, but of course, there are no guarantees: and there are some risks. For example, counseling could open up new levels of awareness that may cause discomfort.

Length of Therapy Many counseling issues can be resolved in 12 or fewer sessions, however some issues require more extensive care. Insurance companies require medical necessity for counseling so your progress will be evaluated throughout treatment and appropriate referrals for continued care after service termination may be discussed. If two months have passed since your last appointment or contact with me your case will be closed. If you choose to return to services at any time in the future your case can easily be reopened and you will be asked to update your information

Confidentiality:  I will not release your confidential information without a written release of information form unless such release is authorized or required by law.  I am a mandated reporter of child and adult abuse/ neglect and intent to harm yourself or others. Medical records are also subject to being subpoenaed and I am required to abide. By signing this description of Services you acknowledge receipt of New Hope Notice of Privacy Practices. This document describes your rights and my obligation regarding the use of your private health information. Please be aware that insurance companies require a mental health diagnosis and other identifying information, including but not limited to, date of birth and address. 

Payment for Services: The fee for the initial 45 minute assessment is billed to insurance for $150. Subsequent 45 minute sessions are billed at $125.00. Please call your insurance company in advance (member services phone number on your health insurance card) for information about what your coinsurance or deductible will be. Please be prepared to pay your copay at each visit. I accept cash, credit, checks, Venmo and Zelle for payment. If you do not have a mental health diagnosis insurance will not cover services and you will be responsible for the fees listed above. Court attendance is billed at $600 for up to a half day, payable in advance, and is not covered by insurance.  Returned check fee is $50.

Appointment Cancellation:  Please notify me with as much advance notice as possible if you cannot keep an appointment so I can offer it to another client. Except in situations of illness, you may be personally charged a $50 cancellation in the absence of a 24 hour notice to offset the lost appointment time. Insurance companies will not cover this fee.  Your phone calls are received 24 hours a day by a confidential voicemail system. Please leave a message and I will make every effort to return your calls as soon as possible. I do not charge for brief phone calls but do charge for ongoing or lengthy phone communication. 

Emergency Phone Contact: Please call 988 for the 24/7 suicide prevention and crisis life line or call 911 if you are in imminent danger of harming yourself or others.

I have read the above information, and understand that I am encouraged to ask questions and give input regarding the counseling process at any time. If there is anything in this form that I do not understand it is my responsibility to seek clarification.