Service Agreement
Amber Gross, LCPC, RPT
9 Bowdoin Mill Island
Topsham, ME 04086
Ph: 207.835.1032 Fax: 207.203.4668
amber@skippingstoneswellnessme.com
www.skippingstoneswellnessme.com
Welcome to Skipping Stones Wellness! I am so pleased to have the opportunity to work with you. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Counseling is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. These rights and responsibilities are described in the following sections.
Disclosure Statement:
I have a Master’s of Science degree in Counseling obtained from the University of Southern Maine. I am a Licensed Clinical Professional Counselor (LCPC) and my Maine License number is CC3952 and my Massachusetts license is 12593. I am also a Registered Play Therapist (RPT). I am trained for work with individuals including children, adolescents, and adults.
Orientation & Treatment Methods:
Many people enter into counseling to heal suffering, to increase well-being and to explore and ultimately understand and move through emotional and psychological obstacles in their lives. It is my belief that effective counseling is guided by the expertise you have about yourself and your willingness to enter into a mutually respectful and professional relationship with a counselor. I use a variety of modalities including play, cognitive behavioral and art therapy.
The process of counseling can sometimes bring up uncomfortable feelings such as sadness, anger, frustration, guilt and helplessness as well as difficulties in relationships and/or life routines as you make positive changes. On the other hand, counseling has been shown to have benefits such as reduction in feelings of distress, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. There are, however, no guarantees in what each individual will experience through counseling. Factors that contribute to the likelihood of positive outcomes include being motivated to change, having open communication with your counselor, feeling respected and understood by your therapist and attending sessions regularly.
Insurance billing:
I am able to bill most major insurance companies. You are asked to know the specifics of any deductible or copay. Payment of your portion of the fee is due at the time of service, at the beginning of each appointment. Initial authorization from the insurance is your responsibility. I will obtain any future authorizations as needed. If your insurance company fails to pay for reasons that are not of my doing, then you will be responsible for that payment. If you have a high deductible plan, you will be responsible for paying the contracted rate.
Financial:
If you do not have insurance the cost of services is $150 per 52-60 minute session, with the initial intake appointment costing $200. If your insurance doesn’t pay for sessions (high deductible, provider is out of network with your insurance company etc), you will be charged the full fee. I take checks, credit card, and utilize an online payment system called IVY pay. In addition, you will be provided with a good faith estimate of services for the year.
Court:
I will not be making recommendations about visitation or custody. In cases where I may be requested to testify,
I have a separate document that outlines my court fees and rates. That will be provided if a situation warrants it.
Cancellations:
Your appointment time is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide a 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24- hour notice, you may be required to pay for the session [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for canceled sessions; thus, you will be responsible for the full fee of $150.
Confidentiality:
Skipping Stones Wellness will make every effort to keep your personal information private. If you wish to have information released, you will be required to sign a consent form before such information will be released. There are some limitations to confidentiality to which you need to be aware.
1. If a client threatens to harm someone else, I am required under the law to take steps to inform the intended victim and appropriate law enforcement agencies.
2. If a client threatens to cause severe harm to themselves, I am permitted to reveal information to others if I believe it is necessary to prevent the threatened harm.
3. If a client reveals or I have reasonable suspicion that any child, elderly person, or incompetent person is being abused or neglected, the law requires that I report this to the appropriate county agency.
4. If a court of law orders me to release information, I am required to provide that specific information to the court.
5. If a client has been referred to me by a court of law for therapy or testing, the results of the treatment or tests ordered may have to be revealed to the court.
Some clients may choose to use technology in their counseling sessions and as a means of communication. This includes but is not limited to online counseling via telehealth platform, telephone, email, fax, text or chat. Due to the nature of online counseling, there is always the possibility that unauthorized persons may attempt to discover your personal information. Skipping Stones Wellness will take every precaution to safeguard your information but cannot guarantee that unauthorized access to electronic communications could not occur. There are limitations to all of the above technology items.
HIPAA:
A copy of the HIPPA policy for this office will be made available to you.
Communication with other providers/attorneys/doctors:
With a signed release, I will reach out to providers/attorneys/doctors as needed and at the request of the client. In addition, there is a fee of $25 per 15 minutes that I spend communicating/coordinating with other providers via telephone, face to face, or e-mail.
Accountability:
The practice of counseling is regulated by the Department of Professional and Finance Regulation. Complaints may be registered by contacting: Board of Counseling Professionals Licensure
35 State House Station Augusta, ME 04333 (207) 624.8674
Consent to Counseling Signature Page
Your signature below indicates that you have read this agreement
and agree to its terms on pages 1-3.
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Client /Parent or guardian signature date
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Printed Name date
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Clinician date
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Amber Gross, LCPC date
HIPAA Form
Amber Gross, LCPC, RPT
9 Bowdoin Mill Island
Topsham, ME 04086
Ph: 207.835.1032 Fax: 207.203.4668
amber@skippingstoneswellnessme.com
www.skippingstoneswellnessme.com
Notice of Privacy Practices
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996. (HIPAA)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you, determining medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
Required by Law. Under the law, we must make disclosures of your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Abuse and Neglect
Judicial and Administrative Proceedings
Emergencies
Law Enforcement
National Security
Public Health
Public Safety (Duty to Warn)
Without Authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. The types of uses and disclosures that may be made without your authorization are those that are:
Required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations (such as the social work licensing board or the health department)
Required by Court Order
Necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Verbal Permission. We may use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.
YOUR RIGHTS REGARDING YOUR PHI (Protected Health Information)
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request to the Privacy Officer at 124 Main St (rear), Topsham, ME 04086.
Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. We may charge a reasonable, cost-based fee for copies.
Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12 month period.
Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.
Right to a Copy of this Notice. You have the right to a copy of this notice.
COMPLAINTS
If you believe we have violated your privacy rights, you have the right to file a complaint with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, DC 20201, or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.
The effective date of this Notice is July 1, 2020