PATIENT SERVICES CONTRACT
Please read this document carefully. It contains important information about every
aspect of this practice. We
will answer any questions you might have about information in
this document.
PSYCHOLOGICAL SERVICES
Psychotherapy is a broad term describing
the delivery of psychological services to patients. There are
a variety of approaches available to address the needs and issues
that you bring to treatment.
Psychotherapy differs from medicine in that it requires
active participation and effort from the patient.
In order for treatment to succeed you need to work on
the issues discussed during treatment outside of the office
during the course of your normal week.
Psychotherapy is not without risk or problems.
Uncomfortable feelings such as sadness, guilt, anxiety, anger,
and frustration often appear during the course of treatment.
Psychotherapy requires that you discuss aspects of your life
that are unpleasant and occasionally embarrassing. Patients
often experience anger with their therapist during the course
of treatment. These feelings are important “grist for the mill”
and require immediate discussion with your therapist.
Psychotherapy also has clear benefits for
most patients including stress reduction, clarity of purpose,
improved relationships and the resolution of individual problems
and symptoms. While the vast majority of our patients terminate
psychotherapy with satisfactory outcomes we cannot guarantee
anyone that they will absolutely benefit from a course of treatment
or the amount of time necessary for you to experience improvement.
The first few sessions are devoted to evaluation
of your problems, symptoms, and needs. We will share our initial
impression with you and discuss a course of treatment with you. Since psychotherapy can involve a significant
commitment of time, money and energy, it is important that you
feel comfortable with your therapist and his or her treatment
approach. If you are not comfortable with your therapist
or the modality of treatment, please let us know immediately
and we will try to refer you to someone who may be a better
match.
Questions and concerns are always
appropriate. Please discuss
them with us as soon as they arise.
EVALUATION
PERIOD
Our usual practice is to conduct an initial
evaluation of your problems and symptoms. This initial evaluation generally takes one
to three 45-minute sessions and involves a detailed personal
history as well as the issues that brought you to our practice.
At the end of this period your therapist will recommend a treatment
modality, i.e. individual, couple, family, or group, and inform
you if a medication evaluation is also recommended.
Once
an appointment is scheduled you are expected to keep it. You
must give us a minimum of 48 hours notice.
IF you do not notify us at our voicemail telephone #781-329-1159,
you will be charged the full professional fee for the appointment.
Please see the Cancellation section of this document
for further details.
FEES
Current fees are listed on the signature
page of this contract. Although
you may have health insurance that may cover much of your treatment
there are also charges for which you are responsible. These
charges include but are not limited to deductibles, co-payments,
and charges that your insurance company categorizes as “not
covered.”
Insurance companies do not generally cover the following fees: non-attendance for scheduled
appointments, late cancellations of appointments, lengthy consultations
with outside sources (i.e. schools, physicians, psychiatrists,
other therapists), letters/written reports, preparations of
records, and treatment summaries.
In regard to the involvement of your
therapist in court proceedings, there is a $500 minimum fee
for the first two hours of any appearance that we might make
in a court of law on your behalf.
Additional courtroom hours are billed at $250.
Depositions and any other legal proceedings are subject
to these same fees.
Payment is required at the time of service
unless you have a health insurance plan with which we are contracted.
If we are members of your plan's provider panel we will bill
your insurance company directly. However, deductible amounts
and co-payments are still due at the time of service.
We do not accept credit or debit cards.
If your account is more than 60 days in
arrears and you have not made suitable arrangements for payment,
we have the option of using legal means to secure payment including
collection agencies and small claims court.
If such legal action is necessary the costs of those
proceedings will be borne by you. In such cases only the minimum
required information would be released; your name address, nature
of services provided, the dates of service, and the amount due.
We strongly recommend that you contact
your insurance company and carefully question them about the
details of your plans. There are over 700 different insurance
plans in Massachusetts. Each of these plans maintains a structure of
fees for which you are responsible.
Deductible, out of network, co-payment, and benefit limitations
are examples of the variable costs that come out of your pocket.
Evaluation of insurance and personal financial resources is
essential to setting realistic treatment goals. Your health
insurance generally includes mental health coverage, but you,
not the insurance company, ultimately bear the responsibility
for full payment of fees. It
is your responsibility to know what your insurance covers and
to confirm with your insurance carrier how your benefit will
work prior to your first visit.
The escalation of health care costs and
new federal and state laws have resulted in an increasing level
of complexity about insurance benefits which makes it more difficult
to determine how much coverage is actually available.
Even if you are eligible for a certain number of visits,
they often must be pre-approved and are based upon “medical
necessity” a term defined by the reviewers employed by insurance
companies. Most plans
are oriented towards short-term treatment; an approach designed
to resolve specific problems and to save money for your insurance
company. We will request
additional sessions if we believe that it is appropriate for
your treatment. However, your insurance carrier does not always
honor these requests.
Insurance companies require, at
minimum, a diagnosis, procedure code, place of treatment, and
date of service for reimbursement.
Most insurance companies require treatment plans, of
varying length and detail, to continue reimbursement after a
few initial sessions and after a fixed amount of session thereafter.
You are entitled to examine these forms and discuss with your
therapist the information they require.
Your signature on this contract signifies your consent
to release this information to your insurance company for reimbursement. HIPPA (Health Insurance Privacy and Protection
Act) regulations require insurance companies to have appropriate
privacy safeguards in place. However, we have no control over
this information once it leaves our office.
PROFESSIONAL RECORDS
Professional standards, state and federal
law require that we keep appropriate treatment records. Your records are kept in a locked space and
are only available to your therapist and designated support
staff who, like your therapist, are bound by law to keep them
in the strictest confidence. You are entitled to a copy of your records unless
your therapist believes that they would be damaging to your
mental health and treatment.
Should this be the case they can be released to a mental
health professional of your choice. Because professional records reflect our years
of training, the language, diagnostic impressions and other
material that reflects professional analysis might be upsetting
to someone who does not have the education and training to fully
understand them. It is for this reason that we require you make
an appointment with your therapist (or his or her designate
should s/he be unable),
to review your records together.
Any request for release of your records,
or any information contained therein, not covered by the insurance
release clause stated above, must be approved by you prior to
release.
CONFIDENTIALITY
The associated psychotherapists
of this practice are bound by statutory rule of confidentiality.
Copies of these statutes (MGL 1112 Section 129A and MGL 233
Section 20 B) are available for your examination. These statutes
state that communication between licensed psychotherapists and
the individuals with whom the therapists engage in the practice
of psychology are confidential but for those exceptions listed
in the General Laws. These
exceptions are generally summarized as follows 1) Dangerousness
to self. 2) Dangerousness to others. 3) Knowledge of sexual
or physical abuse of a child or elderly person.
Physical and sexual abuse revelations are
reported directly to the Massachusetts Department of Social
Services which conducts its own investigation. If you threaten
to harm yourself we must attempt to do what is necessary to
get you to a hospital for treatment and to contact family members
who may be able to assist in your treatment and safety. If you
threaten to harm another person we are required to notify the
intended victim, notify the police, and to seek hospitalization.
In court proceedings you have the right
to prevent your therapist from releasing information about your
treatment. However in rare cases, such as child custody
proceedings, or in which your emotional condition is an important
element, a judge may subpoena your therapist and/or your records
to resolve the matter before the court. Judges generally review
confidential information privately before ruling upon its admissibility
on a case-by-case basis.
We are a group practice and find it helpful
to consult with one another about cases within our group. All consultants are bound by the same rules
of confidentiality noted above.
In these consultations we make every effort to protect
the identity of our patient.
TEENAGE MINORS: RULES AND EXCEPTIONS
If you are under eighteen years of age
the law may provide your parents with the right to examine your
treatment records. It
is our policy to ask parents to give up access to your records.
If they agree, your treatment is bound by the same rules noted
above. Teenagers mature at such rapid and varying rates that
the confidentiality exception, “dangerousness to self “, varies
tremendously. For example, a fourteen year old who drives without
a parent’s permission is exhibiting behavior that is” dangerous
to self”, a seventeen-year-old with a driver’s license is not. We will discuss issues that may impact upon
you confidentiality after evaluation, and guarantee you that
we will not reveal any information to your parents without discussing
it with you first. We will listen to your side of issues and try
to resolve the conflict before we speak to your parents.
CANCELLATION POLICY
Cancellations
must be received at least 48 hours before your appointment.
Managed care companies have reduced our
reimbursement rates by over one third in the past five to seven
years. Many of our colleagues chose to see additional patients
to recover income. We have not. We believe that we can only
see a limited number of weekly patients so that each patient
gets the attention and concentration that s/he deserves. As
a result we must insure that every patient hour is filled.
When you become a Dedham Psychotherapy
patient your time is sacred.
We require that you make the same commitment to us. If you are unable to make an appointment for
any reason you must discuss this with your therapist and agree
upon the cancellation well in advance of the scheduled date. If you do not follow this policy you will be
required to pay the full fee for this appointment. Under contract we cannot bill your insurance
company for canceled appointments.
The fee comes out of your pocket and must be paid prior
to your next scheduled visit.
In the event
of bad weather, your psychologist will leave a message on their
voicemail concerning appointments for the day.
For very early morning appointments, it would help to
listen for school cancellations. However,
it is essential to check our voicemail.
If your therapist has not cancelled appointments, and
you assume there is no meeting, you may be charged for the appointment
at the clinician’s discretion.
CONTACTING US
You may leave a message
on voicemail (781-329-1159)
at any time. We request
that you leave a telephone number and a time to contact you
in the message. We generally do not check our messages on weekends
or holidays.
If, at any
time, you feel that you are a danger to yourself or others,
you must call 911 immediately and request assistance.
Do not wait for us to contact you.
Current Professional Fees
| Initial Evaluation |
$190 |
| Individual Psychotherapy |
$150 |
| Family/Couples Psychotherapy |
$160 |
| Group Psychotherapy |
$50 |
| Forensic Evaluation |
$220 |
| Consults (over 15 min.) |
$160 |
| Court Appearance (2hr. min.) |
$500 |
My signature below indicates that I have read and fully understood
the Patient Services Contract and agree to all fees and specifications
described therein.
Patient _____________________________ Date______________
Legal Guardian
if Under 18
My signature indicates
that will I not seek to review the records of my minor child.
Legal Guardian_______________________________Date_________
I give_________________permission to release and receive information
from the following individuals.
___________________________Init. ________________________
Name
Telephone Date
___________________________Init. ________________________
Name
Telephone Date
___________________________Init. ________________________
Name
Telephone Date