NOTICE OF PRIVACY PRACTICES

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

I. MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you. I create a record of the care and services you receive from me. I need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which I may use and disclose health information about you. I also describe your rights to the health information I keep about you, and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:

• Make sure that protected health information (“PHI”) that identifies you is kept private.
• Give you this notice of my legal duties and privacy practices with respect to health information.
• Follow the terms of the notice that is currently in effect.
• I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my ofOice, and on my website.II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
  The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
  For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization, to carry out the health care provider’s own treatment, payment or health care operations. I may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise conOidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

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Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. Psychotherapy Notes. I do keep “psychotherapy notes” as that term is deOined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorizationunless the use or disclosure is:
   a. For my use in treating you.
   b. For my use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
   c. For my use in defending myself in legal proceedings instituted by you.
   d. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.
   e. Required by law and the use or disclosure is limited to the requirements of such law.
   f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
   g. Required by a coroner who is performing duties authorized by law.
   h. Required to help avert a serious threat to the health and safety of others.
2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
3. Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.

IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.
2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
3. For health oversight activities, including audits and investigations.
4. For judicial and administrative proceedings, including responding to a court oradministrative order, although my preference is to obtain an Authorization from you before doing so.

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5. For law enforcement purposes, including reporting crimes occurring on my premises.
6. To coroners or medical examiners, when such individuals are performing duties authorized by law.
7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.
8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
9. For workers’ compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
10. Appointment reminders and health related beneOits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or beneOits that I offer.

V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the rightto ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.
3. The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a speciOic way (for example, home or ofOice phone) or to send mail to a different address, and I will agree to all reasonable requests.
4. The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information that I have about you. I will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and I may charge a reasonable, cost based fee for doing so.
5. The Right to Get a List of the Disclosures I Have Made.You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided me with

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an Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e- mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on 12/01/2019.

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By checking the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

BY SIGNING ON THE LINE BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.

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Client Signature /Parent Signature (if client is a minor)

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Printed Client Name

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Date

Psychotherapy Agreement

PSYCHOTHERAPY

Psychotherapy varies depending on the personalities of the therapist and client, and the problem(s) being addressed. Often it involves difficult aspects of life and experiencing uncomfortable feelings. Beneficial results depend on an active effort on your part.

Your therapist may use different methods in therapy. Generally our approach invites your close attention to, and the expression of, your internal experience including thoughts, feelings, and recollections of personal history. Together we will explore your perceptions of the world around you. We will identify ways in which you are behaving and ways in which you interact with your world, both those that serve you and those that limit you or create problems.

Your therapist will invite you to explore by talking about personal material, by expressing behaviors (some apparent and some out of your awareness), and by experimenting with new behaviors. The degree to which the therapy is successful often depends on your willingness to practice what is experienced in therapy in your daily life. The intent of this therapy is to help you become a more effective participant in your own life.

Therapy is a unique learning experience we both create. Your therapist provides expertise in recognizing clinically important material and structuring meaningful therapeutic opportunities. You are responsible for saying what is important to you, what you have come to therapy to address, and deciding for yourself what is useful. You always have the right, in fact it is important for you, to raise your own needs and any objections or reservations you may have about what we do. It is not your therapist’s job to tell you what to do. It is your job to make your own decision about what is best for your life.

There are times, despite the best efforts of both the client and the therapist, that the therapy is not helpful. Sometimes a particular therapist or therapeutic approach is simply not a good match. If at any time you feel your therapy with your therapist is not satisfactory, please let us know. If we are unable to make suitable adjustments your therapist will make every effort to locate another therapist for you.

CONFIDENTIALITY AND PERSONAL INFORMATION

The law protects the privacy of all communication between a patient and therapist and dictates how we manage your personal information. Please read the notice entitled “Your Personal Information” about the policies and limitations regarding your privacy. By signing this agreement I acknowledge that I was offered a copy of this document.

APPOINTMENTS

Unless otherwise arranged, therapy sessions are scheduled from 45 to 60 minutes (depending on your insurance coverage or your preference if you are paying on your own). Together we will agree on our frequency of meeting. Weekly or every other week are common frequencies, especially at the beginning of therapy.

A scheduled appointment means your therapist reserves the time only for you. If you need to cancel or reschedule please give as much notice as possible to allow for other clients to schedule in your place. 24 hours noticed is preferred.

If you miss your appointment without giving prior notice (a “no-show”), you will be billed directly according to the following schedule:

1st time: $50
2nd time: $75
3rd time: $100 and discharge from services.
Please note: Insurance companies will not cover these charges, so they will be billed directly to you. If you are a Medicaid client, these charges will not apply, however, upon the 3rd missed session you will be discharged from services.

CONTACTING YOUR THERAPIST
Messages can be left for your therapist at the office number (406) 426-2866. These messages are confidential. Unless we have specifically made other arrangements, YOUR THERAPIST DOES NOT provide on-call phone or emergency sessions. In an emergency contact 911 or a hospital emergency room. If you feel you require special support between your scheduled sessions, please discuss these needs with your therapist.

FINANCIAL TERMS

• Angela Krystal Therapy, PLLC’s standard fee for a psychotherapy session is $140 and the standard fee for couples/ family sessions is $165. The initial intake and assessment session is $180. Angela Krystal Therapy, PLLC charges a fee for communication with legal counsel, courts and probation officers, document gathering and other legal preparation (excluding depositions) of $200 per hour, billable in 15 minute increments (we will also bill this rate for your therapist’s travel time to and from any related destination). The fee for testimony and deposition (in person, on the phone, via Internet, etc.) is $350 per hour (we will also bill this rate for your therapist’s travel time to and from any related destination). These fees are not covered by insurance and will be billed directly to you and/or your attorney and are due and payable upon receipt of invoice.
• Upon verification of insurance coverage and policy limits, your insurance carrier will be billed for your sessions at their designated reimbursement rate. Angela Krystal Therapy, PLLC will be paid directly by the carrier and you will be responsible for any deductibles and co-payments. If your insurance plan determines you are not eligible, you are responsible for full payment at the fee schedule above.
• Insurance will not cover any charges outside of our sessions. Should you require my services outside of our office (other than those mentioned above) or additional services outside of your session (phone calls with you or on your behalf in excess of 15 minutes total per week, records review, etc.), you will be billed directly at our regular hourly rate of $140 per hour in 15 minute increments. You will be responsible for these charges as your insurance will not cover this expense.
• Payment arrangements should be finalized at your first visit.
• In the event of default of payment, the balance is due in full. You will be responsible for any reasonable court costs, attorney fees and/or collection fees incurred.

Please choose one of the following by initialing:

________ I am paying full fee for psychotherapy and am aware that I must pay in full by cash, money order or credit/debit card at the time of service, unless other arrangements have been made.

________ I am electing to have my treatment paid by my insurance carrier or a third party. I will authorize this in writing and allow Angela Krystal Therapy, PLLC to release to an authorized agent of my insurance or a third party payer information about the type(s), cost(s), date(s) and any other required information for any treatment I receive. I am financially responsible for any portion of the fees not covered or reimbursed by my health insurance carrier. Further, I understand that, should my insurance carrier or third party payer, deny payment for treatment sessions with Angela Krystal Therapy, PLLC, I am financially responsible for those sessions not covered.

LIMITS OF COVERAGE, APPEALS AND GRIEVANCES

It can be difficult to determine health plan coverage. Some require authorization before they pay and may limit the number of visits. You have the right to request reconsideration if visits are denied certification. You would appeal through Angela Krystal Therapy, PLLC and have no risk in doing so. If you continue without authorization and your appeal is denied, you will be responsible for payment of sessions not approved at the fee schedule above. You may make a complaint to Angela Krystal Therapy, PLLC or to your therapist about any aspect of treatment. If not satisfied, you may submit a grievance to your insurance carrier.

ELECTRONICS ACKNOWLEDGMENT AND WAIVER

I understand that the use of electronic video/audio recording devices will be used in the waiting area of the office of Angela Krystal Therapy, PLLC. By signing this agreement I acknowledge that I understand and agree to the use of this equipment.

CONSENT FOR TREATMENT

I authorize and request that Angela Krystal Therapy, PLLC carry out behavioral health treatment and/or diagnostic procedures which now or during the course of my care are advisable.

I acknowledge that I have been offered a copy of this Psychotherapy Agreement and have read, understand and agree to what is presented.

I further acknowledge that I have been offered a copy of the notice entitled “Your Personal Information with Angela Krystal Therapy, PLLC”. I authorize the use and disclosure of my information as defined in the notice.

I am aware that the practice of psychotherapy is not an exact science and so predictions of the effect are not precise or guaranteed. I acknowledge that no guarantees have been made to me regarding the results of treatment provided by Angela Krystal Therapy, PLLC or its agents.

I understand that regular attendance will produce the maximum benefit, but that I am free to discontinue treatment at any time. If I decide to do so, I will notify Angela Krystal Therapy, PLLC at least two (2) weeks in advance so that effective planning for termination and or continued treatment elsewhere can be implemented. I am aware that I will still be responsible for payment for the services I received.

This agreement supersedes any and all previous agreements.
I authorize payment of medical benefits to Angela Krystal Therapy, PLLC for services described. I UNDERSTAND AND AGREE TO ALL OF THE ABOVE

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Client Signature

Parent Signature (if client is a minor)

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Printed Client Name

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Date

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Client Date of Birth