THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health Care Options

We may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms here are some definitions.

Y “PHI” refers to information in your health record that could identify you.

Y “Treatment, Payment and Health Care Operations”

Treatment is when we provide, coordinate, or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or psychiatrist.

Payment is when we obtain reimbursement for your health care. Examples of payment are when we disclose 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 our practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

Y “Use” applies only to activities within our [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

Y “Disclosure” applies to activities outside of our [office, clinic, practice groups, etc.] such as releasing, transferring, or providing access to information about you to other parties.

Y “Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

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II. Other Uses and Disclosures Requiring Authorization

We may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when we are asked for information for purposes outside of treatment, payment, or health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes we have made about our conversations during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

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III. Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances:

Y Child Abuse—If we believe that a child is a victim of child abuse or neglect, we must report this belief to the appropriate authorities.

Y Adult and Domestic Abuse—If we believe or have reason to believe that an individual is an endangered adult, we must report this belief to the appropriate authorities.

Y Health Oversight Activities—If the Indiana Attorney General’s Office (who oversees complaints brought against counselors) is conducting an investigation into our practice, then we are required to disclose PHI upon receipt of a subpoena.

Y Judicial and Administrative Proceedings—If the patient is involved in a court proceeding and a request is made for information about the professional services we provided you and/or the record thereof, such information is privileged under state law, and we will not release information without the written authorization of you or your legally appointed representative or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Y Serious Threat to Health or Safety—If you communicate to us an actual threat of violence to cause serious injury or death against a reasonably identifiable victim or victims or if you evidence conduct or make statements indicating an imminent danger that you will use physical violence or use other means to cause serious personal injury or death to others, we may take the appropriate steps to prevent that harm from occurring. If we have reason to believe that you present an imminent, serious risk of physical harm or death to yourself, we may need to disclose information in order to protect you. In both cases, we will only disclose what we feel is the minimum amount of information necessary.

Y Worker’s Compensation—we may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

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IV. Patient’s Rights and Counselor’s Duties
Patient’s Rights:

Y Right to Request Restrictions—You have the right to request restrictions on certain uses and disclosures of protected health information. However, we are not required to agree to a restriction you request.

Y Right to Receive Confidential Communications by Alternative Means and at 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 seeing us. On your request, we will send your bills to another address.)

Y Right to Inspect and Copy—You have the right to inspect or obtain a copy (or both) of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process.

Y Right to Amend—You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

Y Right to an Accounting—You generally have the right to receive an accounting of disclosures of PHI. On your request, we will discuss with you the details of the accounting process.

Y Right to a Paper Copy—You have the right to obtain a paper copy of the notice from us upon request, even if you have agreed to receive the notice electronically.
Counselor’s Duties:

Y We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

Y We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.

Y If we revise our policies and procedures, we will provide you a copy of these revisions at the next appointment.

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V. Questions and Complaints

If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact Rick Russell, Director of White County Community Counseling Services LLC, 574-583-8055.

If you believe that your privacy rights have been violated and wish to file a complaint with our office, you may send your written complaint to WCC Counseling, 126 S Main St, Monticello, IN 47960.

You may also send a written complain to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

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VI. Effective Date: This notice will go into effect on May 23, 2005

I understand I have made a voluntary choice to be involved in counseling provided by a mental health professional as defined by Indiana law. I understand counseling is a cooperative effort between me and my counselor and I agree to keep him/her aware of my needs, resolving any difficulties which may arise. I am free to terminate counseling at any time.

I understand I am consenting only to those mental health services that my counselor is qualified to provide within the scope of the professional (or his/her supervisor’s) license, certification, and training he/she has obtained.

I understand my treatment will be kept in confidence. Release of information will only occur by my informed, signed, and witnessed consent. The only exceptions to this are those required/allowed by law, including but not limited to perpetration of sexual abuse, danger to self or others, and treatment of minors. (Discuss with your therapist questions you might have.)

I authorize the White County Community Counseling Services (WCC Counseling) to release necessary medical information to appropriate third parties for reimbursement purposes and/or to person authorized to conduct service utilization reviews.

I authorize my counselor to contact my Primary Care Physician to coordinate services.

I understand and agree: I am personally and fully responsible to pay for all services rendered; if I have insurance with a carrier which has a contract with White County Community Counseling Services. WCC Counseling will file claims on my behalf, and I agree to pay the balance of any and all services not deemed “reasonable and necessary” by my carrier, as well as any co-payments or other payments according to the terms of the applicable carrier’s contract. I agree to pay in full and non-covered services which are not covered by my insurance carrier.

I understand that I am responsible to give at least 24 hour notice when canceling appointments and that I am responsible to pay for my appointments in full if 24 hour notice is not given. Missed appointments without cancellation notice cannot be billed to insurance.

The services at White County Community Counseling Services are performed by Richard C. Russell, a Licensed Mental Health Counselor by the State of Indiana.

INSURANCE: If you have insurance that includes Mental Health Benefits, each session will be billed at $150. The insurance benefits quoted by your insurance company are not a guarantee of payment. Payment for counseling sessions is contingent upon your current benefit eligibility, available mental health/substance abuse benefits and medical necessity. Please note that benefits can change periodically and may affect the amount that your insurance company will pay. The final confirmation of your benefits and co-pay will appear on the Explanation of Benefits that you receive from the insurance company. You will be financially responsible for any remaining amount that is not covered under your Mental Health Benefits of your insurance policy.

SLIDING SCALE FEES
If you are not covered by insurance, your fee is determined by your annual household income according to the sliding scale below.

Annual Income
Under $15,000 Fee $50
$15,001-20,000 Fee $55
$20,001-25,000 Fee $60
$25,001-30,000 Fee $70
$30,001-35,000 Fee $75
$35,001-40,000 Fee $80
$40,001-50,000 Fee $85
$50,001-70,000 Fee $100
$70,001-100,000 Fee $110
Over $100,001 Fee $120

PAYMENT
Payment for counseling is due at the end of your counseling session. This helps keeps our counseling fees as low as possible. Checks should be made out to White County Community Counseling Services or WCC Counseling. For your convenience, we also accept Visa, MasterCard, American Express and Discover. Payment for counseling is due at the end of your counseling session.


SESSIONS and CANCELLATIONS
Scheduled appointments are an agreement between client and counselor that requires at least a 24 hour notice to cancel or change without penalty. All clients will be expected to pay a flat $60 fee or their sliding-scale fee (which ever is lower) for an appointment that is missed or canceled with less than a 24 hour notice. In case of emergencies (i.e. weather or unexpected illness), you will not be charged.