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Client Information

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Terms and Policy

HIPPA NOTICE OF PRIVACY
THIS NOTICE DESCRIBES HOW YOUR PRIVATE HEALTH INFORMATION MAY BE USED AND DISCLOSED, AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Private Health Information (PHI) may be used and disclosed in the following circumstances:
1. Information that is necessary in order to file insurance claims and successfully complete all billing and collection procedures.
2. When required for public health issues such as workman's compensation.
3. When required by any state or federal law, including cases of abuse and neglect.
4. When required for any specialized government or military functions including active personnel, reservists, veterans, and discharged members of the military service. Also, for any person confined to a correctional institution or under any law enforcement supervision.
5. When used for any clerical purposes and necessary chart audits by managed care companies.
As a client, you have rights to your Private Health Information, including,
1. The right to review your records or receive a copy of your records at any time by signing a written release. However, under certain rare circumstances your request can be denied. If needed, interpretation of the records will be provided. Requests for records will be honored within 30-60 days.
2. The right to request information of any party that has requested information pertaining to your private health information.
3. The right to receive confidential information regarding your private health information.
4. The right to revoke this consent in writing; however, this will not affect any information already disclosed.
As a private practitioner, I have the responsibility to:
1. Make each client aware of the Privacy Notice.
2. At any time make the necessary changes to the Privacy Notice that are required by law.

Another important element to take into account as a client of Therapy Works is you may come into contact with another client whom you may know, it is important to understand that if you are to find yourself in such situations that you are responsible for keeping that information private and confidential. The Privacy Rule can be further researched at 45 CFR Part 160 and Part 164, Subparts A and E. The enforcement of the privacy rule is required by law.

If you as the client feel your privacy has been violated you have the right to complain by filing a written complaint with the Secretary of Health and Human Services in Washington, D.C.

I understand the above statements, and hereby authorize Peter Daniels, LCSW to release private health information on my behalf to the following persons or company: Do not release any Private Health Information to outside parties.
( Type Full Name )
OFFICE INFORMATION AND POLICIES
I appreciate the trust you have shown in making this appointment. It is my intention to provide you with effective, personalized and constructive mental health services. Below is some information about my office policies.

1. I hope my office is a place where you can comfortably and safely work on resolving your concerns. Please let me know if there is anything in the office which interferes with that process.
2. My waiting room is shared with other professionals and is not set up for unsupervised children under the age of 12.
3. Notify me as soon as possible, and no later than 24 hours in advance, when canceling or rescheduling an appointment. The reason for this is simple: you have contracted for a portion of my time, and if you don't show up that time is empty. Missed appointments and late cancellations (i.e. less than 24 hours notice) incur a full fee charge.
4. I understand that unusual circumstances occur that might keep you from an appointment. Let me know if such a situation occurs.
5. Payment is preferred at the time of service. If necessary, I will be happy to talk with you about other payment arrangements. I accept cash, checks, credit/debit and Paypal.
6. You are responsible for payment of all fees. Where possible I will assist in helping you to understand any out of network mental health benefits you may have under an insurance plan and endeavor to provide you with the supporting documentation for your reimbursement.
7. I check my voice mail messages frequently throughout the day 512.470.3243. I am usually able to return calls within three hours. I can also be reached via email at therapist@anewentry.org. In a life-threatening situation call 9-1-1 or go to the nearest emergency room.
8. If you are seeing a psychiatrist or physician for medication, you will need to speak with your doctor or their representative about questions related to your medication. If a problem exists, contact your physician(s) or pharmacist immediately.
9. Let me know if you have any problem with my services. It is constructive to work out concerns sooner than later.
10. If you have unresolved concerns about my professional social work services, you can contact The Texas State Board of Social Worker Examiners in Austin at (512) 719-3521.
( Type Full Name )
FEE INFORMATION AND CONTRACT
The following list shows my fees for professional services.

Psychotherapy (Individual)
50 minutes $150
90 minutes $225
Other times are prorated accordingly

Psychotherapy (Couples)
50 minutes $150
90 minutes $225
Other times are prorated accordingly

Group Therapy
1.5hrs+ $55

Reports, letters
up to 45 minutes preparation time $150
greater than 45 minutes (will be discussed on an individual basis)

Court or Deposition Services $250/hr

These fees do not reflect any sliding scale adjustments which might be applied. The total is due at time of service unless alternative arrangements have been made with Mr. Daniels.

I have read the Office Information and Policies, and Fee Information and Contract forms. I agree to participate in assessment and agreed-upon treatment services with Mr. Daniels. I understand the fees and payment policies, and agree to pay all professional fees in a timely manner as discussed with Mr. Daniels and as outlined on the above-mentioned forms.
( Type Full Name )