Informed Consent
Phone/Text: 855.995.6777; Fax: 509.676.6655
INFORMED CONSENT
FOUNDATIONS FAMILY SUPPORT LLC
Phone/Text: 855.995.6777; Fax: 509.676.6655
INFORMED CONSENT
Welcome to services with Foundations! This document will walk you through what therapy and medication management will look like and how you or your family can be empowered to find the information you will need to make healthy and informed choices. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
You will learn about:
Contact and Communication
Billing
Appointment Attendance and Cancellations
Telephone Accessibility
Social Media
Minors and therapy (ages 13 and under)
Health Statement
The Therapeutic Process
Completion of Services
Confidentiality
Electronic Communications
Consent for Telehealth
Consent for using Telehealth with SimplePractice
Protected Health Information
Disclosed Information
Consent to Disclose Information
Rights and Grievances
About Your Therapist
You have taken a very positive step by deciding to seek therapy and/or medication support. The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual and professional agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for your work together with your provider. Feel free to discuss any of this with your provider as well.
CONTACT AND COMMUNICATION
You are welcome to contact your provider via phone, email, or preferably, secure messaging via the client portal. Your provider will provide you with their extension and you are welcome to leave a message to receive a returned call. You can also call our reception line as well.
PHONE: 855.995.6777
FAX: 509.676.6655
It is recommended that you download our client portal app: SimplePractice Client Portal for most up-to-date information on your appointments.
Your provider may need to cancel your appointment due to illness or crisis. You will be informed of any cancellations via secure messaging in the client portal.
It is important that you check your email or your client portal prior to each session to confirm.
By signing this consent form, you agree to be contacted by phone, email, and text message (NOTE: data and messaging rates may apply).
BILLING
Our hourly rate for providing psychotherapy is $220 per hour (53+ minutes). This will be billed to your insurance. You will be responsible to pay all co-pays and fees not covered by insurance. Those paying out of pocket, or billing out-of-network, will be provided a Good-Faith Estimate of costs.
If your insurance plan has a deductible, co-pay, or co-insurance, you agree to provide a payment method and consent to enrolling in autopay.
Insurance Information
For those with state-funded medicaid plans, there are very rarely any co-pays or extra charges. However, the following terms can be helpful for you to understand your insurance plans and coverage. It is up to you to know your plans and coverages. You can reach out to your insurance provider via the number on the back of your card.
Deductible: The amount that needs to be paid out of pocket before insurance will pay
Co-Pay: A set amount that is paid out of pocket per visit
Co-insurance: A percentage of the rate that needs to be paid out of pocket
Out-of-network: Billing an insurance plan wherein there is no established contract with Foundations
Be sure to inform your provider if you are unable to afford the costs of therapy and if you are in need of a sliding scale fee reduction. More information on sliding scale can be found at www.foundationsfamilysupport.com
APPOINTMENT ATTENDANCE AND CANCELLATIONS
The standard meeting time for psychotherapy is 53 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 53-minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
Your provider may need to cancel your appointment due to illness or crisis. You will be informed of any cancellations via secure messaging in the client portal.
It is important that you check your email or your client portal prior to each session to confirm.
No-show/Late Cancel Policies:
Cancellations, no-show, and rescheduled sessions will be subject to a fee of $20 unless planned 24 hours in advance or you are on State-Funded Medicaid. This is necessary because a time commitment is made to you and is held exclusively for you. Additionally, therapy and medication management is a science and we have research that reinforces the benefit of regular attendance. If you are late for a session, you may lose some of that session time.
Cancellation (no fee): Appointment is canceled 24 hours in advance
No-show ($20): Client is more than 15 minutes late to appointment
Late Cancel ($20): Appointment is canceled with less than 24 hours notice
If there are two consecutive no-show/late cancelations, your provider will no longer be able to hold this opening. You will need to contact your provider and schedule within 7 days to maintain enrollment in services.
A $50.00 service charge will be charged for any checks returned for any reason for special handling.
Should you fail to schedule an appointment for three (3) consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, your provider must consider the professional relationship discontinued.
TELEPHONE ACCESSIBILITY
If you need to contact your provider between sessions, please leave a message on their voicemail. As they are often not immediately available; however, they will attempt to return your call within 24 hours. Texting the main line during office hours will reach the front desk and will be retuned within 1-2 business days. Please note that face-to-face or Telehealth sessions are highly preferable to phone sessions as phone sessions are not covered by insurance. In the event that you are out of town, sick or need additional support, Telehealth sessions are available. If a true emergency situation arises, please call 911, 988, or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, your provider or any Foundations’ staff do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Twitter, LinkedIn, etc). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when you meet with your provider so it can be discussed further.
MINORS AND THERAPY (AGE 13 AND UNDER)
If you are under the age of 13, your parents may be legally entitled to some information about your therapy. Your provider will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential. Parents/guardians must inform us of all guardians whom have medical decision-making rights. If you are 13 years old or older, you have the decision-making rights in your care.
HEALTH STATEMENT
It is important that you are aware that we offer Telehealth therapy thus making your presence in-office optional. Should you choose to attend in-office appointments, you are agreeing to do so only when feeling well and following current State, Local and/or CDC guidelines (CDC.gov). In addition, you are doing so at your own risk and Foundations or our providers are not liable for any communicable health conditions that may or may not be contracted in attending in-office appointments or in the transportation to/from these appointments. Note that our providers are taking all reasonable precautions with regard to sanitization as well and may cancel appointments at any time citing health concerns.
THE THERAPEUTIC PROCESS
The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. Foundations cannot promise that your behavior or circumstance will change. Foundations can promise to support you and do our very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
COMPLETION OF SERVICES
Therapy has a beginning, a middle, and an end. Ending relationships can be difficult. Therefore, it is important to have a graduation process in order to achieve some closure. The appropriate length of graduating therapy depends on the length and intensity of the treatment. Your provider may conclude treatment after appropriate discussion with you and has worked through the graduation process. If your provider determines that the psychotherapy is not being effectively used or if you have failed to complete payment your provider will not end the therapeutic relationship without first discussing and exploring the reasons and purpose of ending unless you have not been in contact with our offices. If therapy is ended for any reason or you request another therapist, Foundations will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
CONFIDENTIALITY
The session content and all relevant materials to the treatment you or your family receive will be held confidential unless you request in writing to have all or portions of such content released to a specifically named person/persons/organization. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated in item #3 in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally, your provider may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If you accidentally see your provider outside of the therapy office, they will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to us at Foundations, and we do not wish to jeopardize your privacy. However, if you acknowledge your provider first, they will be more than happy to speak briefly with you, but feel it inappropriate to engage in any lengthy discussions in public or outside of the therapy office.
ELECTRONIC COMMUNICATION
FOUNDATIONS cannot ensure the confidentiality of any form of communication through electronic media, including, but not limited to, text messages.
If you prefer to communicate via email for issues regarding scheduling or cancellations, your provider will do so. While they may try to return messages in a timely manner, they cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
You agree to be contacted via text message for appointment reminders, confirmations, and other scheduling outreach (Note: data and messaging rates may apply).
CONSENT FOR TELEHEALTH CONSULTATION/PSYCHOTHERAPY
I understand that my provider offers me and/or my family the opportunity to engage in a Telehealth session.
My provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/ provider visit due to the fact that I will not be in the same room as my provider.
I understand that a Telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing, within the State of Washington.
I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my provider or I can discontinue the Telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE:
Telehealth by SimplePractice is the technology service we will use to conduct telehealth video conferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911 or 988.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my Telehealth appointment link with anyone unauthorized to attend the appointment.
PROTECTED HEALTH INFORMATION
Foundations understands that health information about you and your health care is personal. We are committed to protecting health information about you. Your provider creates a record of the care and services you receive from them. Your provider needs 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 your provider may use and disclose health information about you. Below is described your rights to the health information your provider keeps about you, and describe certain obligations they have regarding the use and disclosure of your health information. Your provider is required by law to:
Make sure that protected health information (PHI) that identifies you is kept private.
Give you this notice of your provider’s legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
Your provider can change the terms of this Notice, and such changes will apply to all information they have about you. The new Notice will be available upon request, in their office, and on their website.
HOW YOUR PROVIDER MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
The following categories describe different ways that your provider uses and discloses health information. For each category of uses or disclosures there will be an explanation as well as some examples. Not every use or disclosure in a category will be listed. However, all of the ways your provider is 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 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 provider’s own treatment, payment or health care operations.
Your provider may also disclose your protected health information (PHI) for the treatment activities of any provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed provider about your condition, they would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other 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 providers with a third party, consultations between providers and referrals of a patient for health care from one provider to another.
Lawsuits and Disputes: If you are involved in a lawsuit, your provider may disclose health information in response to a court or administrative order. Your provider 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.
Places where your PHI is subject to certain limitations in the law, your provider can use and disclose your PHI without your Authorization for the following reasons:
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.
For public health safety, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners, when such individuals are performing duties authorized by law.
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.
Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counterintelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although Foundations’ preference is to obtain an Authorization from you, your provider may provide your PHI in order to comply with workers' compensation laws.
Appointment reminders and health related benefits or services. Your provider may use and disclose your PHI to contact you to remind you that you have an appointment with them. Your provider may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that they offer.
CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. Your provider does keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
For their use in treating you.
For their use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.
For their use in defending themselves in legal proceedings instituted by you.
For use by the Secretary of Health and Human Services to investigate their compliance with HIPAA. Required by law and the use or disclosure is limited to the requirements of such law.
Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.
Required by a coroner who is performing duties authorized by law.
Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. Your provider will not use or disclose your PHI for marketing purposes.
Disclosures to family, friends, or others. Your provider 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.
YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI.
You have the right to ask your provider not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Your provider is not required to agree to your request, and your provider may say “no” if they believe it would affect your health care.
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.
The Right to Choose How Your Provider Sends PHI to You.
You have the right to ask your provider to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and they will agree to all reasonable requests.
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 your provider has about you. Your provider 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 your provider may charge a reasonable, cost based fee for doing so.
The Right to Get a List of the Disclosures Your Provider Has Made.
You have the right to request a list of instances in which your provider has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided your provider with an Authorization. Your provider will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list your provider will give you will include disclosures made in the last six years unless you request a shorter time. Your provider will provide the list to you at no charge, but if you make more than one request in the same year, your provider will charge you a reasonable cost based fee for each additional request.
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 your provider correct the existing information or add the missing information. Your provider may say “no” to your request, but will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice.
You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by email. And, even if you have agreed to receive this Notice via email, you also have the right to request a paper copy of it.
YOU HAVE THE RIGHTS TO FILE GRIEVANCE:
Informing your provider and allowing them an opportunity to correct any mistakes.
If you believe that a mistake has been made in your care, you can let your provider know about this and they will do their best to correct this. If you are not comfortable talking to your provider about this issue, you are welcome to contact someone else on our team or in our administration office: 509-822-6777 ext 200. This includes any mistakes regarding insurance billing, charges, invoices, clinical care, ethics, and/or legal/privacy concerns.
Filing complaints with State or Federal offices.
If you believe that your provider has broken the law or has violated ethical standards in treatment, you have the right to file a grievance with State or Federal agencies responsible for maintaining their licensure and/or overseeing HIPAA compliance. In doing so, your provider is maintaining their right to advocate for my decisions in protecting their license and in doing so, may disclose your PHI.
ABOUT YOUR THERAPIST
You can learn more about your therapist by going to: www.foundationsfamilysupport.com/mytherapist