This Agreement contains important information about professional services and business policies at Rasi Associates, Inc. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a 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.
HIPAA requires that we provide you with a Notice of Privacy Practices for use and disclosure of Protected Health Information (PHI). The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information. It is very important that you read all these documents carefully. You can discuss any questions you have about the procedures with your therapist at any time.
When you sign these documents, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on your therapist unless he/she has already taken action or if there are obligations imposed on us 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 SERVICES The process of psychotherapy is difficult to describe in general terms. The methods, length and frequency might vary depending on the problems you want therapy to address and the particular problems you are experiencing. Psychotherapy 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 have to work on things talked about in your therapy session, both during the sessions themselves and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable or difficult feelings. You might also discover that resolving some of these problems and feelings requires time. Psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.
The first few psychotherapy sessions might involve an evaluation of your needs and a chance for you and your therapist to determine what the treatment might look like. It is always important for you and your therapist to develop a comfortable and trusting relationship together. You should evaluate this and talk about it with your therapist. In the event that you or your therapist finds it necessary, your therapist will be glad to offer you another referral. It is important to remember that therapy involves a large commitment of time, money, and energy.
MEETINGS The frequency of your sessions depends on the agreement made between you and your therapist. Sessions last 45--50 minutes. If you cancel or miss an scheduled appointment, you will be expected to pay the full fee of $140/$155 for it unless you provide at least 24 hours (prior business day) advance notice of cancellation; (for example if your appointment is on Monday at 2:00 P.M. you must cancel by Friday at 2:00 P.M.) It is important to note that insurance companies do not provide reimbursement for cancelled sessions.
PROFESSIONAL FEES The fees at Rasi Associates are as follows: for individual therapy $155 for the initial evaluation, $140 for the follow-up sessions; for couples/families $170 for the initial evaluation, $155 for the follow-up sessions; and $55 for a standard group meeting. These are the amounts that your insurance will be charged and the amount you will be charged in case of a short notice cancellation or no show.
In the event of a bounced check, you will be charged a $25 processing fee.
In addition to appointments, Rasi Associates charges $140 for 45 minutes spent on other professional services you may need. If less than 45 minutes is spent on a particular task, the cost will be prorated accordingly in 15 minutes increments. These services might include report writing, telephone conversations lasting longer than 15 minutes, preparation of records or treatment summaries, and the time spent performing any other service you may request. If you become involved in legal proceedings that require your therapist's participation, you will be expected to pay for all of his/her professional time, including preparation and transportation costs, even if he/she is called to testify by another party.
CONTACTING US Your therapist will inform you of the best way to contact him/her, and will explain the procedure to reach our emergency therapist on call. Those directions will also be on the Rasi Associates general voice mail at 617.266.2266, prompt 4. If you have questions about appointments or billing, leave a message in the general voice mail and the appropriate person will call you back.
LIMITS ON CONFIDENTIALITY The law protects the privacy of all communications between a patient and a therapist. In most situations, a clinician can only release information about your treatment 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, advance consent. Your signature on this Agreement provides consent for the use and disclosure of PHI for the purposes of treatment, payment, and health care operations and for those activities, as follows:
1. Your therapist may occasionally find it helpful to consult other health and mental health professionals about a case. During some of these consultations, every effort will be made to avoid revealing your identity. The other therapists consulted are also legally bound to keep the information confidential. Your therapist might choose not to tell you about these consultations unless he/she feels that it is important to your work together. All consultations will be recorded in your Clinical Record.
2. You should be aware that there are other mental health providers and administrative staff at Rasi Associates. In most cases, we will need 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 except as is allowed by HIPAA for the treatment, payment, and healthcare operations.
3. Rasi Associates also has contracts with business associates (e.g., accountants, lawyers, consultants.) As required by HIPAA, Rasi Associates has a formal business associate contract with these businesses, in which they promise to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, Rasi Associates can provide you with the names of these organizations and/or a blank copy of this contract. If so desired, please make your request in writing an address it to: Dr. Lourdes Rodriguez-Nogues, Director.
There are some situations where a clinician is permitted or required to disclose information without either consent or Authorization:
1. If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the therapist-patient privilege law. A therapist cannot provide any information without your (or your legal representative's) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order your therapist to disclose information.
2. If a government agency is requesting the information for health oversight activities, clinicians may be required to provide it for them.
3. If a patient files a complaint or lawsuit against his/her therapist, the therapist may disclose relevant information in order to defend him/herself.
4. If a patient files a worker's compensation claim, we must, upon appropriate request, provide appropriate information, including a copy of the patient's record, to the patient's employer, the insurer or the Department of Worker's Compensation.
There are some situations in which therapists are legally obligated to take action and reveal some information about a patient's treatment in order to protect the patient and/or others from harm. In our experience, these situations do not occur often:
1. If a therapist has reasonable cause to believe that a child under age 18 is suffering physical, sexual or emotional abuse resulting in harm or substantial risk of harm to the child's health or welfare, the law requires that a report be filed with the Department of Social Services. Once such a report is filed, the clinician may be required to provide additional information.
2. If a therapist has reason to believe that an elderly or handicapped individual is suffering from abuse, the law requires that a report be filed with the Department of Elder Affairs. Once such a report is filed, the therapist may be required to provide additional information.
3. If a patient communicates an immediate threat of serious physical harm to an identifiable victim or if a patient has a history of violence and the apparent intent and ability to carry out the threat, therapists are required to take protective actions. These actions may include that the patient write a safety contract, notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient.
4. If a patient threatens to harm himself/herself, therapists are obligated to request a patient to sign a safety contract,
to seek hospitalization for him/her, or to contact family members or others who can help provide protection.
If such situations arise, your therapist will make every effort to fully discuss it with you before taking any action and he/she will limit the disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you and your therapist discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, thus in situations where specific advice is required, formal legal advice may be needed.
PROFESSIONAL RECORDS You should be aware that, pursuant to HIPAA, we keep Protected Health Information about you in two sets of professional records.
One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that are received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. You may examine and/or receive a copy of your Clinical Record if you request it in writing unless your therapist believes that access to it would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that if you request to examine them, you initially review them with your therapist, or have them forwarded to another mental health professional so you can discuss the contents.
In addition to the Clinical Record, your therapist might keep a set of Psychotherapy Notes. These Notes are for the clinician's own use and are designed to assist him/her in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of therapy conversations, analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to your therapist but is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record.
While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of the Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of the Psychotherapy Notes unless your therapist determines that it would adversely affect your well-being. In that case you have a right to a summary or to have your record sent to another mental health provider or your attorney.
PATIENT RIGHTS HIPAA provides you with several new or expanded rights with regard to your protected health information. These rights include requesting that your therapist amends 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 complaints you make about Rasi Associates' policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the attached Notice form, and Rasi Associates' Privacy Policies and Procedures. You are welcomed to discuss any of these rights with your therapist. (A more thorough description of these rights appears in the Notice of Privacy Practices form.)
MINORS AND PARENTS Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child's treatment records, unless the clinician believes this review would be harmful to the patient and his/her treatment.
Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child's records. If they agree, during treatment, the therapist will provide them only with general information about the progress of the child's treatment, and his/her attendance at scheduled sessions. Any other communication will require the child's Authorization, unless the therapist feels that the child is in danger or is a danger to someone else, in which case, he/she will notify the parents of the concern. Before giving parents any information, the therapist will discuss the matter with the child, if possible, and do his/her best to handle any objections the client might have.
BILLING AND PAYMENTS You will be expected to pay for each session at the time it is held: - full fee, deductible or co pay. Payment schedules for other professional services will be agreed to when they are requested. Please remember that you must give us at least 24 hours (prior business day) advance notice if you need to cancel an appointment, otherwise you will be charged our full fee for the time you reserved. (For example if your appointment is on Monday at 2:00 P.M., you must cancel by Friday at 2:00 P.M.)
We require that you fill out a credit card authorization sheet. In the unlikely event that you accrue a balance, Rasi Associates will charge your credit card for the balance owed for more than 21 days since the last date of service or 21 days since the last payment. If you accrue a balance and we are unable to charge your credit card your account will be charged an additional 1.5% interest on each unpaid monthly cycle. At that time, your therapist will not be able to schedule further appointments until your balance is paid. Rasi Associates reserves the right to send delinquent accounts to collection. Please refer to the Cancellation, Billing and Accounts Receivable Policy form for more details.
INSURANCE REIMBURSEMENT In order for you and your therapist 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. Your therapist will fill out forms and provide you with assistance to help you receive the benefits to which you are entitled. It is important for you to know, however, that ultimately it is you, and not your insurance company, who are responsible for full payment of the fees.
We request that you take primary responsibility for finding out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator or your insurance company directly to determine your exact benefits. Of course, Rasi Associates will provide you with whatever information we can based on our experience and we will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we 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 difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans 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 therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end.
You should also be aware that your contract with your health insurance company requires us to provide it with information relevant to the therapy you receive. Your therapist will be required to provide a clinical diagnosis. Sometimes he/she will be required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, your therapist will 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, we have 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. If you request it, you can be provided with a copy of any report your therapist submits. By signing this Agreement, you agree that your therapist can provide requested information to your insurance company.
Once we have all of the information about your insurance coverage, you and your therapist might want to discuss what you can expect to accomplish with the insurance benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you always have the right to pay for therapy yourself.
QUESTIONS AND CONCERNS In the unlikely event that you and your therapist come to a disagreement that you cannot resolve, or, if you have a complaint of a serious nature about the services at Rasi Associates, you have a right to be heard. You can contact Dr. Lourdes Rodriguez-Nogues, Director. She can be reached at 617.266-2266 Ext.126.
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS. YOUR THERAPIST WILL ALSO SIGN THIS AGRREMENT, INDICATING A CONTRACT BETWEEN YOU AND HIM/HER.
YOUR SIGNATURE HERE INDICATES YOUR AGREEMENT THAT YOU HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES FORM EXPLAINING YOUR RIGHTS UNDER HIPAA.
YOUR SIGNATURE HERE INDICATES THAT YOU HAVE RECEIVED A CANCELLATION, BILLING AND ACCOUNTS RECEIVABLE POLICY FORM EXPLAINING RASI ASSOCIATES' BUSINESS PRACTICES REGARDING YOUR FINANCIAL OBLIGATIONS.
Name of Patient (Print)
Signature of Patient
Name of Therapist (Print)
Signature of Therapist
Rev. 3/07 Rasi Associates, Inc. 607 Boylston Street, Boston, MA 02116 617. 266.2266