Mandatory Disclosure/Informed Consent/HIPPA Information
Licensed Psychologist: Colo. License # 1934
The practice of both licensed and unlicensed persons and certified school psychologists in the field of psychotherapy is regulated by the Department of Regulatory Agencies. The address and telephone for the grievance board is below:
1560 Broadway
Suite 1340
Denver, CO 80202
Phone # 303-894-7766
Some Basic Informed Consent Information: Psychotherapy is not guaranteed to “make you better” or to “work”. We will be working toward your goals, and the purpose is for you to accomplish what you wish to gain from therapy, but there are not guarantees. Also, when discussing, or dealing with psychological, mental, behavioral, emotional, and memory material, you might experience some sense of distress. Please let me know about this so we can discuss it and deal with it. Basically, this psychotherapy is for you, and about your goals, and you are in control in that you are not required to do anything in therapy against your will. You may choose to engage in processes that are uncomfortable for you in order to achieve gains in therapy. However, you can choose to let me know that you do not want to engage in a process that I may suggest. I reserve the right to not engage in a therapeutic process with you that you have requested if in my professional opinion it would be harmful for you. In general, if you are unhappy, displeased, upset, disappointed, or unsatisfied with any part of our therapy process, billing or anything else, please bring these issues if there are any to my attention so we can discuss it and deal with it. It is important to remember that the therapeutic relationship is a professional relationship designed to help you, and it has limits. The relationship is designed to be helpful to you, and cooperative, and collaborative, and friendly. But, we are not “friends“. For example, I am not allowed to accept gifts from you, give you rides in my car, etc . If I refer you to another professional, it would be only for the purposes of advancing your therapeutic work (e.g., another therapist, or psychiatrist, etc.). If it seems appropriate I might recommend that you see a physician for physical medical issues that may be impacting you, including regarding your mental, psychological or emotional state.
You are entitled to receive information about the methods of therapy, the techniques used, and the duration of therapy, if known, and the fee structure. You may seek a second opinion from another therapist or may terminate therapy at any time. The fact that I do an initial assessment with you is not a guarantee that I will accept you as a client. If you attend therapy sessions, participate in treatment planning and feedback with me, and indicate that you are attempting to do therapy, I will presume that you are engaged in informed consent for therapy. In rare instances therapy has been associated with negative effects. Other alternatives to therapy exist to deal with psychological, emotional, and behavioral issues. I can not state definitively that you will be worse off if you do not do therapy. Therapy can be terminated by me for legitimate reasons (e.g., missing a lot of appointments, you stop attending appointments, you do not pay for services, you do not take responsibility for working on goals established, it becomes my opinion that our therapy together is not helping you, or if you or someone connected with endangers or threatens me). In a professional relationship, sexual intimacy is never appropriate and should be reported to the grievance board. Generally speaking, the information provided by and to a client during therapy sessions is legally confidential if the therapist is a certified school psychologist, a licensed psychologist, a licensed clinical social worker, a licensed professional counselor, a licensed marriage and family therapist, or an unlicensed psychotherapist practicing under the supervision of a licensed psychotherapist. If the information is “legally confidential”, the therapist cannot be forced to disclose the information without the client’s consent. HOWEVER: There are exceptions to the general rule of legal confidentiality. These exceptions are part of Colorado law (see section 12-43-218. C.R.S. (1988), in particular). You should be aware that except in the case of information given to a licensed psychologist, legal confidentiality does not apply in a criminal or delinquency proceeding, or possibly with regard to an at risk adult (e.g., elderly, disabled). There are other exceptions that I will identify to you if the situation(s) arise during therapy. In general, confidentiality can be broken if you are a danger to yourself, or others, or are incapable of taking care of your self (i.e., unsafe), or if you appear to be in the midst of a medical emergency. Also, I am required to report child abuse. If you are a minor, and I feel you are engaging in high risk behavior, I may inform you parents or custodian. If you are a minor, it is possible that your parents/custodian(s) could get information from your record. There may be laws that come to be where reporting of adult abuse could also be mandatory. Although Privileged Communication does exist in Colorado, there are certain circumstances where a judge can over rule this and require confidential information to be provided. In general, it is probably not a good idea to assume that if any court or legal process is involved, that confidentiality, or privilege is guaranteed. In other words, potentially, all of your records with me are potentially discoverable, especially if mental health is identified as an issue in the legal proceedings. Certain information will be provided to third party payers (e.g., insurance companies, employee assistance programs, etc.) for billing purposes. Also, third party payers may audit some files, and could audit your file and have access to information from your file. If we do couples counseling I will not guarantee to keep “secrets” you have disclosed from your counseling partner. If you have any questions or doubts about confidentiality, please ask me now. Confidentiality may also be broken in the case of any filing with a licensing or regulatory board, organization, or agency, or if a malpractice lawsuit is filed. In general I prefer to use cognitive-behavioral, solution focused, psychoeducational, and strength based approaches. If we decide to use EMD/R, you should know that it may still be considered to be an experimental technique. Techniques that involve visualization or guided imagery could lead to retrieval of a repressed memory. If you participate in group therapy, it is necessary for you to agree to protect and respect the privacy of other group members. You need to agree not to share personal information, including the names of other group members with people outside of group. Please let me know if you believe another group member has violated this privacy.
Payment for services is expected, and it is possible that you could be charged on a sliding scale. Nonpayment for services could result in termination of services and referral elsewhere (e.g., local mental health center). If at any time you are in treatment with me and you feel you have a life and death emergency, please take care of yourself and call 911 or go to the nearest emergency room, which ever seems most appropriate. If I do not respond to you when you have left me a message either on voice mail, or via email, or any other communication method, within what you consider a reasonable period of time, please do not assume I actually got your message, and please contact me again. If we were to incidentally meet in public, I will act as if I do not know you (to protect confidentiality) unless you initiate contact with me. If I am taking a vacation or will be unavailable for a set period of time, I will let you know in person if possible, and this information will be available on my voice mail along with the phone number and name of a colleague that you can contact if necessary. If in my professional opinion (either initially or during the course of treatment) I feel that treating you is outside my area of competence, or that you would be better served by a referral, that referral will take place. Chronic no showing for appointments can be a reason for termination of therapy, and a referral elsewhere. If I contact you after a no show, or cancellation, or when we have no future appointment scheduled, and you do not respond to my outreach, I may assume that you have terminated therapy. If you have any questions or would like additional information, please feel free to ask. If you feel you are not making adequate progress, or for some reason feel that another therapist could be more beneficial to you, let me know and I will offer to refer you to another mental health professional.
I am not an expert witness. I have expertise in clinical psychology, but not in forensics. It is considered an ethical violation for a psychologist to “act” outside of his/her “scope of practice”. Also, acting in a “dual role” with a client can be considered an ethical violation. Therefore, as you psychotherapist, my focus is to help you obtain your therapeutic goals, and to be involved in a professional role with regard to legal/court related goals you might or might not have in addition to my role as your therapist could constitute an unethical multiple role relationship. Forensic and therapeutic roles are generally considered to be incompatible. For example, I would not have an opinion in a court related process about, what is in the best interest of children, disability, work performance, etc. It also states in the DSM-IV, that it is inappropriate to infer specific functioning from a diagnostic label.
In general, I tend to use a more cognitive-behavioral approach to psychotherapy. I tend to focus on helping people learn to consciously, and effectively utilize their thinking, emotions, and behavior in a coordinated or integrated way. We will develop therapeutic goals, and will try to stay “on target” with regard to your priorities for treatment. I will also want the approaches or methods we use to make sense to you, and will ask you to discuss, question, etc., if the approach being used does not make sense to you. I also tend to focus on you having something related to your goals to work on in between sessions. I also take into consideration environmental, physiological, and developmental factors. The first or intake session is typically one hour and fifteen minutes long. “Regular” sessions are typically 50 minutes long. I do make notes during an intake, and make notes about each session. My main focus with these is to provide clinical information for myself to track what we are doing, and for other professionals should they be in a position to use this clinical information at some point. A third party payer may limit the number of sessions they will pay for, or the type of issue that they pay for. For example, your insurance may not pay for couples counseling.
NOTICE OF INFORMATION PRACTICES, PRIVACY RIGHTS, AND FEDERAL REQUIREMENTS REGARDING CLIENT RECORDS (HIPPA): Effective 4-14-03. (privacy notice, administrative, policies and procedures, permitted uses and disclosures of protected health information, uses and disclosures with authorization). In general, it is possible that protected health information concerning you could be released with it being as accurate as possible and known, in good faith, for a legitimate purpose designed to be helpful, and allowing you to provide information for proper treatment and evaluation with regard to other professionals. In general, release of information, even with a signed release, is limited to the minimum necessary by my best clinical and legal judgment and counsel. There are some restrictions on what information can be used. In general, is usual and customary practice when billing a third party to provide some information, and this may include a diagnosis, date of service, and the type of service, and in some cases other information. This document represents part of the HIPPA documentation required. This notice describes how medical information (including the information gathered in our therapy or treatment) about you may be used and disclosed, and how you can get access to this information (about you). Please review it carefully. It is possible that information could be released in a legal or court process where mental health is at issue. Records could be discoverable in a legal process, or with a court order. Information about you and your health is personal. Thus, Federal and State guidelines will be followed to maintain the confidentiality of your health information. Your information is safeguarded via administrative, physical, and technical means. “Health” information refers to information that identifies you and relates to your medical and/or behavioral health history, care, or payments made for that care.
Federal law and regulations are such that your health information can not be released unless you consent in writing, the disclosure is allowed by a court order, or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit (including a payer source i.e., insurance or managed care company), or treatment evaluation. Violation of Federal law and regulation is a crime. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or Local authorities. (See 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 or Federal laws and 42 CFR pt. 2 for Federal regulations.)
Your information is used for normal (e.g., routine) business activities that by Federal law fall into the categories of treatment, payment, and health care operations. Below are some examples of how your health information could be used and disclosed relative to these aforementioned categories (although not every such use or disclosure is listed here). Please note that I might be required to, or choose to limit the condition of the release of certain information about you for the purposes mentioned above and listed below. For example, I would not disclose psychotherapy notes or information about your treatment for substance use without getting your specific consent.
Treatment: Treatment refers to the provision, coordination, or management of health care (including mental health care) and related services by one or more health care providers. I keep a record of telephone consultations and appointments. This record might include your diagnoses (if any), medications, and your response to medications and other therapies. For example, if you were referred to a psychiatrist regarding depression, the psychiatrist might wish to know your symptom history in this regard. Your health information might also be disclosed in the context of coordinating your care with other providers (e.g., psychiatrists, nurses, other therapists, substance abuse counselors, etc.). (Remember, in order for this information to be released you would have to provide your written consent.)
Health Care Operations: Health information is used in order to improve the services I provide. For example, a third party payer may review some of your health information in order evaluate my performance.
I may also contact you to remind you of appointments or to tell you about treatments and other services that might be of benefit to you. This means that information could be left via a phone message or a letter to you.
Other Uses and Disclosures: I may also use information to:
Recommend treatment alternatives.
Tell you about health related products and services.
Communicate with other treatment or payer organizations.
To help entities that assist me in providing services where they agree to safeguard your information.
Comply with Federal, State or Local laws that may require disclosure.
Attempt to avert a serious threat to health or safety.
Assist in public health activities such as tracking diseases or medical devices.
Inform workers’ compensation carriers and/or your plan if your are injured at work and are making a claim for workers’ compensation.
Inform authorities to protect victims of abuse or neglect, or crime information.
Inform authorities if you are a victim of abuse, neglect or domestic violence if I believe disclosure is necessary and either you agree to the disclosure or we are required by law to make the disclosure.
Comply with Federal and State health oversight activities such as fraud investigations.
To plan sponsors as specific in plan documents.
Respond to law enforcement officials or to judicial orders, subpoenas or other process.
Assist in specialized government functions such as national security, intelligence, and protective services.
Conduct research following strict internal review to ensure to ensure the balancing of privacy and research needs.
I may be required to release information without your consent for health oversight activities where required by law, when required to report certain communicable diseases or certain injuries, when a Coroner is investigating a death, if a crime is committed against me or observed by me on by business premises, and business associates who have agreed to maintain the privacy of health information (e.g., quality assurance, billing, legal counsel, auditing). If you are treated involuntarily information can be shared pursuant to law with other treatment providers and legal entities as necessary to provide the appropriate care. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if you (the client) object, protected health information will not be disclosed. Again, in life threatening emergencies information may be disclosed in order to avoid serious harm or death.
All other uses and disclosures, in categories not previously described, may only be done with your written permission. Should such permission be obtained from you, you may revoke it at any time, but I am unable to take back disclosures made in reliance on your permission.
My Responsibilities: To maintain the privacy of your health information in accordance with Federal and State rules. To provide this notice of my duties and privacy practices. To abide by the terms of the notice currently in effect. I reserve the right to change privacy practices, and make the new practices effective for all the information I maintain. Revised notices will be made available.
Your Federal Rights: The law entitles you to;
- Inspect and copy certain portions of your health information. This request must be made in writing, and fees may apply for copying. This does not include psychotherapy notes, and I may deny your request under limited circumstances.
- Request amendment of your health information if you feel that it is incorrect or incomplete. This request must be made in writing. If I deny your request, you can file a statement of disagreement. I am not required to amend the record if it is determined that it is accurate and complete.
- Receive and accounting of certain disclosures of your health information made after 4-14-03, although this excludes certain disclosures including those made for treatment, payment, and healthcare operations. These requests must be made in writing, and fees may apply.
- Request that I restrict how I use or disclose your health information. This request must be made in writing. (I may not be able to comply with all requests.)
- Request that I communicate with you in a certain way or at a specific address. This request must be made in writing. This usually done if a client is concerned that confidential information may be accessed by others unless special provisions are made (e.g., sending mail to a different address, or not leaving messages on a home phone, etc.).
- Obtain a paper copy of this notice even if you receive it electronically.
What if you have a complaint?
If you believe that your privacy has been violated, you may file a complaint with your third party payer, or with the Secretary of Health and Human Services in Washington, D.C. I will not retaliate or penalize you for filing a complaint. To file a complaint with the Secretary of Health and Human Services, write to:
Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Ave.
S.W., Room 515F, HHH Bldg.
Washington, D.C. 20201 or call 1-877-696-6775.
This notice applies to health care professionals and to me as a health care provider.
If you want more information, please ask me.
Client Statement: I have read and understand the above, and have received a copy of this Mandatory Disclosure, and a copy of the Notice of Information Practices (which includes Federal confidentiality rules, notice of your privacy rights, copy of your rights as a client, and the complaint process), and I hold that I am competent to understand this material and can knowingly sign this document with awareness.
_____________________________________________________ ______________
Signature of Client or Parent/Legal Guardian (if client is under age 15) Date
If you think of any questions after having read this please write them below and address them with me.
Release of Information:
___ RELEASE/REQUEST OF CONFIDENTIAL INFORMATION FOR TREATMENT, PAYMENT, AND OPERATIONS (This is often used to authorize information required for billing to be sent to third party payers.)
___ AUTHORIZATION for other purposes. If this line is checked, this form is a HIPAA compliant Authorization. As such, Mark Rush may not condition treatment, payment, enrollment or eligibility for benefits on your signing this Authorization.
NAME:__________________________________________________ DATE OF BIRTH:_____________
I authorize that information may be exchanged between the following and Mark Rush.
NAME ADDRESS
________________________________ ___________________________ Phone_______________
___________________________ FAX________________
___________________________
Specific Information To Be Released: The execution of this form does no authorize the release of information other than that specifically checked below. There is potential for the information released to be disclosed by the recipient and it may no longer be protected by HIPAA Privacy Regulation.
___ Diagnosis ___ Summary of Treatment ___ Recommendations ___Length of Treatment
___ Psychological Testing/Evaluation ___Drug and/or Alcohol Treatment Information
___ HIV/AIDS Status ___ Written Report ___ Information by Phone, email, fax, or regular mail.
___Other (specified) _____________________________________________________________________
DATES COVERED: ___________________ ___ All Admissions ___ Most Recent Admission
The above information may be provided at the request of the individual for the following purpose(s):
_____________________________________________________________________________________Client Statement: I understand that if I have authorized the release of drug and/or alcohol information the Federal Law (42 CFR, Pt. 2) protects the confidentiality of this information. I understand that if I have authorized the release of HIV/AIDS status this information is protected from unauthorized disclosure as provided by Colorado Law (CRS 18-4-412). Recipient: If you have received information via this release, this information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR pt. 2). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR pt. 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
This release of confidential information is being made in compliance with the Privacy Act of 1974 (Public Law 93-579), Freedom of Information Act of 1974 (Public Law 93-502), Federal Rule of Evidence 1158 (Inspection of Copying of Records upon Patient’s Written Authorization), This authorization serves as both a general and specific authorization to release information under the Drug Abuse Office and Treatment Act of 1972 (Public Law 92-255), and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment, and Rehabilitation Act Amendments of 1974 (Public Law 93-282), the Veterans Omnibus Health Care Act of 1976 (Public Law 94-581), and the Veterans Benefit and Services Act of 1988 (Public Law 100-322), and in compliance with 42 C.F.R. Part 2 (Public Law 93-282), which prohibits further disclosure without the express written consent of the person to whom it pertains, or as otherwise permitted by such regulations. I understand that if the person or organization that receives this information is not a health care provider or health insurer the information may no longer be protected by federal privacy regulations. Client Statement: I certify that this request has been made voluntarily. I understand that I may revoke this release/authorization at any time by written notice to Mark Rush, except to the extent that action has already been taken to comply with it. Without my written revocation, this release/authorization will expire ONE YEAR from the most recent date signed. I hereby release the above parties from liability that may result from furnishing information. A copy of this release/authorization may be utilized with the same effectiveness as an original. I choose for this release to expire on ___________________ (date).
Charges may apply for copies: $14.00 for up to 10 pages, $.50 per page for pages 11-40, and $.33 for each additional page beyond 40.
___________________________________________________________ ____________
Signature of Client, Parent/Guardian (for client under 15 years of age) Date
________________________________________ ___________________________________________
Signature and date to extend request Signature and date to extend request
No Show Policy, and other policy information:
NO SHOW POLICY A no show is defined as either not canceling an appointment, or canceling the appointment less than 24 hours in advance of the set appointment time. If a no show occurs you can be charged a $70.00 no show charge fee. Insurance companies do not pay for cancelled appointments or no shows. By signing this document you are agreeing to this policy. Thank you!
AFTER HOURS COVERAGE
During working hours I check my voice mail very regularly and will return your call as quickly as possible. In the case of something truly urgent, my phone is on overnight, and most likely I will answer the phone directly. If not, that would mean I am on the phone with someone else, and I will know someone else tried to call. Leave a message and I will call you back as quickly as I can. If you have an imminent life and death emergency please take care of yourself immediately and call 911 or go to the nearest emergency room.
MORE INSURANCE INFORMATION
I ask clients before our first appointment to either contact their third party payer (e.g., health insurance company, or EAP authorization agent, etc.), or my billing service, to get an authorization for payment in place before we meet. If this is not done, and the third party payer does not pay for our first session, you are responsible for paying for the session yourself, out of pocket. There may be limits on the number of sessions or the amount that your insurance will pay for psychotherapy. You may have a deductible and/or co-payment that you may be responsible for. Basically, you are responsible for paying for charges if your third party payer does not pay. If you have any questions about any of that, please discuss this with me. Thank you.
Returned Checks
My bank, at this time, charges $20.00 for returned checks. If that happens, you are responsible for the returned check fee, and for reissuing a valid check for the amount of the returned check.
THANK YOU!
________________________________________________ _______________
Client Signature Date
Revised: 06/01/2010
__________________________________________ _____________________________
Client Name Client Name (for couples)
(Clients receive a copy of their treatment plans, if you do not have a copy let me know, so I can give you one.)
TREATMENT PLAN
GOALS AND OBECTIVES: approximate time frames
PLANS TO ACHIEVE GOALS AND OBJECTIVES:
SOME CLIENT RESPONSIBILITIES:
Truthfulness and forthrightness on the part of the client will likely enhance the probability of favorable outcomes in therapy.
Putting forth genuine effort regarding the goals/objectives and treatment plan will likely enhance the probability of favorable outcomes in therapy.
An unwillingness on the part of the client to do the above can be reason for termination of therapy and/or possible referral to another provider.
___________________________________________ _________________
Client Signature Date
Treatment Notes:
____________________________________________________
Client Name(s)
SI/HI/GD issues? (with date):
Notes related to goals/objective and treatment plan:
Intake Assessment: Date: ___________________
Client Name(s)
Presenting Problem (description and history of problem(s):
Previous Treatment:
Medical/Physical Issues:
Other Current Providers:
Medications:
Substance Use Issues:
Trauma History:
HI/SI/GD Issues:
MSE+DSM Data:
Intake Continued: ___________________________________________ ___________
Name(s) Date
(brief formulation)
DX:
I
II
III
IV
V
R/O
Cultural/Diversity Issues:
Support System(social/family history):