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Preferred Care Counseling, LLC 

Notice of Policies and Practices to Protect the Privacy of your Health Information 



Uses and Disclosures for Treatment, Payment, and Health Care Operations: 

A clinician may use or disclose your Protected Health Information (PHI) for the treatment, payment, and healthcare  operations purpose with your consent. To help clarify these terms, here are some definitions: 

PHI- refers to information in your health record that could identify you. 

Treatment- is when a provider coordinates or manages your health care and other services that are related to your  health care, such as consulting with another health care provider or clinician. 

Payment- is when reimbursement is obtained for your health care. Examples of payment are when disclosing your  PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations- are activities that relate to the performance and operation of the practice. Examples of  health care operations are quality assessment and improvements activities, business-related matters such as audits  and administrate services and case management and care coordination. 

Use- pertains only to activities within the practice group, such as sharing, employing, applying, utilizing,  examining and analyzing information that identifies you. 

Disclosure- applies to activities outside of the practice group, such as releasing, transferring or providing access to  information about you to other parties.

Uses and Disclosures Requiring Authorization: 

A clinician may use or disclose PHI without your consent in the following circumstances:


Child Abuse; If, in the professional capacity, knowledge or suspicion is obtained that a child under 18 years of age, or a mentally, developmentally or physically impaired individual under the age of 21 has suffered or faces a threat  of suffering any physical or mental would, injury, disability or conditions of a nature that reasonably indicates  abuse or neglect, the clinician is required, by law, to immediately report that knowledge or suspicion to the Ohio  Public Children Serves Agency, or a municipal or county peace officer. 

Adult and Domestic Abuse; If there is reasonable cause to believe that an adult is being abused, neglected, or  exploited, or is in a condition which is the result of abuse, neglect or exploitation, the clinician is required, by law,  to immediately report such belief to the County Department of Jobs and Family Services. 

Judicial or Administrative Proceedings; If you are involved in a court proceeding and a request is made for  information about your re-evaluation, diagnosis or treatment, and the records thereof, such information is  privileged under state law and will not be released without written authorization from you or your  personally/legally appointed representative or a court order. The privilege does not apply when you are being  evaluated by a third party or where the evaluation is court order. You will be notified in advance if this is the case.


Serious Threat to Health or Safety; If a clinician believes that you pose a clear and substantial risk of imminent  harm to yourself or others, disclosure of relevant confidential information to public authorities, the potential  victim, other professional and/or your family in order to protect against such harm may take place. If you  communicate an explicit threat of inflicting serious harm or causing the death of one or more clearly identifiable  victims, and if you have the intent and ability to carry out the threat, then the law requires one or more of the  following actions to be taken in a timely manner:


1. Take steps to hospitalize you on an emergency basis. 

2. Establish and undertake a treatment plan calculated to eliminate the possibility that you will carry  out the threat, and initiate arrangements for a second opinion risk assessment with another mental  health professional. 

3. Communicate to a law enforcement agency and, if feasible, to the potential victim(s) or victim’s  parent or guardian if a minor, all of the following: (a) nature of the threat (b) your identity  

(c) the identity of the potential victim. 

Workers' Compensation; If you file a worker’s compensation claim, it may be required to give your mental health  information to relevant parties and officials. 

Right to Request Restrictions; You have the right to request restrictions on certain uses and disclosures of  protected health information pertaining to you. However, the practitioner is not required to agree to a restriction  you request.


Right to Receive Confidential Communications by Alternative Means and Alternative Locations; You have the  right to request and receive confidential communications of PHI by alternative means and at alternative locations.  For example, you may not want a family member to know that you are receiving services. Upon request, your bills  could be sent to another address. 

Right to Inspect and Copy; You have the right to inspect and/or obtain a copy PHI regarding mental health and  billing records used to make decisions about you for as long as the PHI is maintained in the record. You may be  denied access to PHI under certain circumstances but, in some cases, you may have this decision reviewed. On  your request, the details of the request process will be discussed with you. 

Right to Amend; You have the right to request an amendment of PHI for as long as the PHI is maintained in the  record. Your request may be denied. At your request, a discussion of the details of the amendment process will be  held. 

Right to Accounting; You generally have the right to receive an accounting of disclosures of PHI for which you  have neither provided consent nor authorization (as described in section 3 of this notice). At your request, the  details of the accounting process will be discussed with you. 

Right to a Paper Copy; You have the right to obtain a paper copy of this notice upon request, even if you have  agreed to receive the notice electronically. 

Professional Duties 

Professional is required, by law, to maintain the privacy of PHI and to provide you with notice of the professional's legal duties and privacy practices with respect to PHI. 


If you are concerned that a professional has violated your privacy rights, or you disagree with a decision the  professional has made about access to your records, you may contact the U.S. Departments of Health and Human  Services at

Effective Date, Restrictions and Changes to Privacy Policy 

This policy goes into effect July 1, 2010. 

The professional reserves the right to change the privacy policies and practices described in this notice. Unless the  professional notifies you of such changes, the professional is required to abide by the terms currently in effect. If  the professional revises policies and procedures, you will be provided with a revised notice, either by hand, mail or electronically.


Preferred Care Counseling, LLC 


If you have medical insurance:
We will file claims to your medical insurance company for the services that are provided by our office. In order for the claims to process correctly, please ensure that the information that is provided to our office on the patient information form is accurate and current. If there is a change in insurance information please let us know immediately. We will submit to secondary insurance as long as we are given the correct information and we are notified that you would like this services done.

Deductibles, Co-Payments, and Co-Insurance:
Co-Payments are constant and due at the time the services is rendered. Co-Insurance and deductibles vary for each insurance policy and we can only approximate the percentage covered by each plan. Payment of the estimated portion is due at the time of service.

A copy of your insurance card is required at the time of the initial service. Often times, the behavioral health benefits are under a separate company and we must contact them to verify the necessity of an authorization. If a copy of the card is not on file at the initial service and the claim is denied for “no authorization”, you will be responsible for the payment.

Provider Coverage:
We are able to provide you with our list of providers who participate with your insurance company. However, we are not responsible for ensuring that our provider is covered under your particular plan provision. Each insurance company has multiple plans. The provider may participate with the insurance company, but not your particular plan. Please contact your insurance company to verify that the provider you are seeing is appropriately covered. It is ultimately your responsibility to verify coverage for your particular plan. If the insurance company denies the claim for the claim for a plan provision, you will be responsible for the balance.

Medical insurance coverage is a contract between you and your insurance company. We are not a party to this contract. We will not be involved in disputes between you and your insurance company regarding deductibles, co-payments, covered charges, secondary insurance, “usual and customary” charges, etc., other then to supply factual information as necessary. You are ultimately responsible for the timely payment of your account.

Payment methods and other information:
We accept Cash, Check and major credit cards. Accounts can be set up on payment plans if necessary at no additional cost. Accounts that are past due will be turned over to collection agency and reported to the credit bureau. All late cancellations and no shows will be billed $30 automatically ($30 first occurrence, full fee thereafter.) We require 24-hour notice in advance to avoid charges.

We are committed to provided you with the best possible care and we are willing to discuss our professional fees at anytime. Your clear understanding of our Financial Policy is important to our relationship. Please ask if you have any questions about our fees, Financial Policy or your financial responsibility.

I acknowledge that I have read and agree to the above financial policy.


Preferred Care Counseling, LLC 


Welcome to Preferred Care Counseling, LLC. This agreement contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), the federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPPA requires that you are provided with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, explains HIPPA and its application to your personal health information in greater detail. The law requires your signature acknowledging that you have been provided with this information before or at the time of your initial consultation. Any questions you might have about the procedures can be discussed at the time of your initial consultation. Although these documents are lengthy and complex, it is important that you read them carefully. The signed document will represent an agreement between you and the clinician/practice. You may revoke this Agreement in writing at any time. That revocation will be binding unless the clinician has taken action in reliance on it; if there are obligations imposed on the clinician by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.


Psychotherapy/counseling is not easily described in general statements. It varies depending on the personalities of the clinician and client, and the particular problems that you hope to address. Psychotherapy/counseling is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will need to work on those things discussed both during the sessions and at home. 

Psychotherapy/counseling can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustrations, loneliness, and helplessness. On the other hand, psychotherapy/counseling has also been shown to have benefits. It can often lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no assurances of what you might experience. 

The first few sessions will likely involve an evaluation of your needs. By the end of the evaluation, some impressions will be offered as well as a plan for treatment, if you decide to continue. You should evaluate this information along with your own opinions of whether you feel comfortable working with the clinician. Psychotherapy/counseling involves a large commitment of time, money, and energy, so you should be careful about the clinician you select. If you have questions about procedures, they should be discussed. If your doubts persist a meeting with another mental health professional for a second opinion can be arranged. 


Typically, an evaluation will last from 2-4 sessions. During this time, you and the clinician will decide if they are the best person to provide the services you need in order to meet your treatment goals. 

Psychotherapy/counseling is usually scheduled as a 45 minute session (one appointment is equivalent to 45 minutes in duration) once per week at an agreed upon time. However, this can vary depending on individual needs and availability. Once an appointment has been scheduled, you will be expected to pay for it unless your provide 24 hours advance notice of cancellation (with exceptions being circumstances beyond your reasonable control). It is important to note that insurance companies do not provide reimbursement for cancelled appointments. If it is possible, another time will be offered to reschedule cancelled appointments. 


Professional fees are determined by the professional licensure of the service provider rendering the services and/or the nature of the clinical work. A specific list of fees is available upon request. Professionals will generally discuss fees with you at the time of the first visit. Services requiring legal involvement invoke fees for all professional time, including preparation and transportation costs, even if the clinician is called to testify for another party. 


Clinicians are often not immediately available by telephone, as they are at most times meeting with patients. The office telephone will be answered by a secretary during office hours. If no secretary is available, a voicemail answering service may be used. Every effort will be made to return your call on the same day you make it. Please provide phone numbers at which you can be reached and some times when you will be available. If you are unable to reach your clinician and feel you can’t wait for a return call, contact your family physician or the nearest emergency room and ask for the psychologist or psychiatrist on call. 


The law protects the privacy of all communications between a patient and a clinician. In most situations, information about your treatment can only be released to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written prior consent. Your signature on this Agreement provides consent for the activities as follows: 

A clinician may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, every effort is made to avoid revealing the identity of the patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, you will not be informed about these consultations unless it is deemed important.  All consultations will be noted in your Clinical Records (Which is referenced as the “PHI” in the Notice and Policies and Practices to Protect the Privacy of Your Health Information).

Your should be aware that this practice includes other mental health professionals and administrative staff.  In most cases, it is necessary to share protected information with  these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance.  All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member. 

This practice has contracts with an various businesses (for example collection agency, etc.) As required by HIPPA a formal business associate contract with this/these business(s), in which it/they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law, has been established. 

Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in the Agreement. 

There are some situations whereby the clinician is permitted or required to disclose information without either your consent or Authorization. 

If you are involved in a court proceeding and a request is made for information concerning your evaluation, diagnosis or treatment, such information is protected by the privileged communication law. The clinician cannot provide any information without your (or your personal or legal representative’s) written authorizations, or a court order.  If you are involved in or are contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order the clinician to disclose information. 

If a government agency is requesting the information for health oversight activities, the clinician may be required to provide it for them. 

If a client files a complaint or lawsuit against the clinician, that clinician may disclose relevant information regarding the client in order to defend him/herself. 


There are some situations in which the clinician is legally obligated to take actions, which he/she believes are necessary to attempt to protect others from harm. In doing so, the clinician may have to reveal some information about a client’s treatment.

If the clinician knows or has reason to suspect that a child under 18 years of age, or a mentally retarded, developmentally disabled, or physically impaired individual under the age of 21, has suffered or faces a threat of suffering any physical or mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the child/ individual, the law requires that the clinician file a report with the appropriate government agency, usually the Children Services Agency. Once such a report is filed, the clinician may be required to provide additional information. 

If the clinician has reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, the law requires that the clinician report such belief to the county Adult Protective Services. Once such a report has been filed, the clinician may be required to provide additional information. 

If the clinician knows or has reasonable cause to believe that a client has been the victim of domestic violence, he/she must note that knowledge or belief and the basis for it in the client’s record. 

If the clinician believes that a patient presents a clear and substantial risk of imminent serious harm to him/herself or someone else and he/she believes that disclosure of certain information may serve to protect that individual, then the clinician must disclose that information to the appropriate public authorities, and/or the potential victim, and/or professional workers and/or the family of the client. 

If such a situation arises, the clinician will make every effort to fully discuss it with you before taking any action that will limit the disclosure to what is necessary. 

While this written summary of exceptions of confidentiality should prove helpful in informing you about potential problems, it is important that you discuss with the clinician any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and clinicians are not attorneys. In situations where specific advice is required, formal legal advice may be needed. 


The laws and standards of psychology and counseling professions require that the clinician keep Protected Health Information (PHI) about you in your Clinical Record. Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your Clinical Record, if you request in writing and the request is signed by you and dated not more that 60 days from the date submitted. Because these are professional records, they can be misinterpreted and/or upsetting to the untrained readers. For this reason, it is recommended that you initially review them in the presence of the clinician or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, the law allows clinicians to charge a copying fee of $1 per page for the first ten pages, 50 cents per page for pages 11 through 50, and 20 cents per page for pages in excess of fifty, plus a $15 fee for records search plus postage. If your request for access to your records is refused, you have the right of review, which will be discussed with you upon request. 


HIPPA provides guidelines and policies regarding  your rights to your Clinical Record and disclosures of protected health information. These rights include requesting that the clinician amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaint you make about policies and procedures recorded in your records; and the right to paper copy of this Agreement, the Notice form, and privacy policies and procedures. 


Clients who are under 14 years of age and who are not emancipated, along with their parents, should be aware that the law allows parents to examine their child’s treatment records unless the clinician decides that such access would injure the child, or parties have agreed otherwise. Children between the ages of 14 and 18 years of age may independently consent to and receive up to 6 sessions of psychotherapy/counseling services provided it is within a 30 day period. No information about those sessions can be disclosed to anyone without the child’s agreement. While privacy in psychotherapy/counseling is often crucial to successful progress, particularly with teenagers, parental involvement is also essential to successful treatment. For children 14 and over, it is policy to request an agreement between the client and his/her parents allowing the clinician to share general information about the progress of the child’s treatment and his/her attendance at scheduled sessions. The clinician will also provide parents with a summary of their child’s treatment when complete. Any other communication will require the child’s Authorization, unless the clinician feels that the child is in danger, or is a danger to someone else, or a threat to property, in which case, the clinician will notify the parents of the concern. Before giving parents any information, the clinician will discuss the matter with the child, if possible, and will do his/her best to handle any objections the child may have. 


You will be expected to pay for each session at the time it is held, unless agreed to otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. 

If your account has not been paid for in more than 60 days and arrangements for payment have not been agreed upon, Preferred Care Counseling, LLC has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, the only information that the clinician will release regarding a client’s treatment is his/her name, the nature of services provided, dates of service and the amount due. 


In order for Preferred Care Counseling, LLC, to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. Preferred Care Counseling, LLC will fill out forms and provide you with whatever assistance it can in helping you receive the benefits to which you are entitled. However, you (not your insurance company) are responsible for full payment of the clinician’s fees. It is very important that you find out exactly what mental health services your insurance policy covers. 

You should carefully read the sections in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, Preferred Care Counseling, LLC will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, Preferred Care will be willing to call the company on your behalf.. 

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficulty to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more psychotherapy/counseling after a certain number of sessions. While much can be accomplished in short term psychotherapy/counseling, some clients feel that they need more service after insurance benefits end. Some managed-care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, the clinician will do their best to find another provider who will help you continue psychotherapy/counseling. 

You should also be aware that your contract with your health insurance company requires that the clinician provide it with information relevant to the services provided to you. The clinician is required to provide a clinical diagnosis. Sometimes the clinician is required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, the clinician will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, the clinician has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. The clinician will provide you with a copy of any report they submit, if your request it. By signing this Agreement, you agree that the clinician can provide requested information to your insurance carrier. 

Once Preferred Care Counseling, LLC has all of the information about your insurance coverage, it will be possible to discuss what can be accomplished with the benefits that are available and what will happen if they run out before you feel you are ready to end your sessions. It is important to remember that you always have the right to pay for the clinician’s services to avoid the potential problems described above. 

Service Agreement
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