C. Paula Krentzel, Ph.D.
223 Walnut Street Suite 20, Framingham, MA 01702
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Date:CLIENT INFORMATION SHEET
Name: / Date of Birth:Address: / Home Phone:
Cell Phone:
Email: / Office Phone:
(Please asterisk those phone numbers where I may leave message, when necessary)
Sex: M F (please circle) Marital Status: S M W D (please circle)
Family member information:
Name / Relationship / D.O.B. / OccupationEmergency Contact: / Relationship:
Telephone:
Primary Care Doctor: / Telephone:
Referred by:
Insurance Carrier:
Subscriber: / Employer:
Group #: / Policy #:
Date of Last Medical Examination:
Major Health Issues:
Current Medications:
C. Paula Krentzel, Ph.D.
223 Walnut Street Suite 20, Framingham, MA 01702
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PATIENT SERVICES AGREEMENT
Welcome to my practice. This document (the Agreement) contains important information about my services, fees, appointments, how to reach me, confidentiality, record keeping and the Health Insurance Portability and Accountability Act (HIPAA), a new federal law regarding patients’ rights. Please read this Agreement as well as the additional documents supplied. I will be happy to answer any questions you may have.
SERVICES
I provide psychotherapy services to children, adolescents and adults. Treatment may be provided on an individual basis or the focus may be on a relationship; for example, an adult couple or even a whole family. Sessions usually last 45 minutes. The treatment itself may vary according to the focus/problem and your decisions and needs.
Also, occasionally I may recommend a medication evaluation to help in the treatment process. When necessary, I will refer patients to an out-of-practice psychopharmacologist or their primary care physician.
FEES, INSURANCE, AND BILLING INFORMATION
If you have insurance coverage, I advise that you read your policy carefully, and all that pertains to mental health coverage including deductibles, copayments, maximums, exclusions, etc. Each company has its own set of rules. I will make every effort to help you with this process before treatment begins. However, in the event your insurance company does not pay as quoted, the charges will be directed to you, as you are ultimately responsible for all fees, not the insurance company. All uninsured charges, e.g., copays, deductibles, etc., must be paid at the time of services.
You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional information such as treatment plans or summaries or, in very rare circumstances, copies of your entire clinical record. This is to substantiate the medical necessity of treatment. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit if you request it. By signing the Signature Page in this packet of information, you agree that I can provide requested information to your carrier.
Please read the Fee Schedule page which details charges that may be made to both you or your insurance carrier. Also, please be advised of my policy on unpaid balances. I have the option to use legal means to secure payment which may mean filing suit in Small Claims Court. This action, although taken very infrequently, requires me to disclose otherwise confidential information. In most situations, the only information that is released is a patient’s name, the responsible party’s name, the nature of the debt and the amount due.
Billing your insurance company is completed either through the insurance carrier’s web site or through an online billing software service. A billing service is used to complete these transactions. The billing service has access to all relevant information needed by your insurance company for the transaction to be completed. The billing service is bound by the same HIPAA regulations as I am.
APPOINTMENTS
You may cancel an appointment with no charge, provided 24-hours notice is given. I have 24-hour voicemail for your convenience. Missed appointments or last-minute cancellations with less than 24-hours notice given will result in a charge to you (see Fee Schedule) and must be paid prior to or at the next session. Insurance companies do not pay for missed appointments. To cancel an appointment, always call my voicemail at 508-872-8208.
REACHING ME
You can leave a message for me on my voice mail line at any time at 508-872-8208. During the week, I will check my messages when I am not in the office. If your call is for a clinical emergency, please contact me through my pager at 978-764-6574. When I am away, my voicemail will advise you as to who is covering for me and how to reach them. On rare occasions, mechanical failures do occur with phone systems and pagers. If you do not receive a return call promptly, and it’s an emergency, I advise you to visit your local emergency room.
HIPAA, CONFIDENTIALITY, RECORD KEEPING
HIPPA, the Health Insurance Portability and Accountability Act, provides privacy protections and patient rights with regard to the use and disclosure of Protected Health Information (PHI) used for the purpose of treatment, payment and health care operations. HIPAA requires that I provide you with a notice of privacy practices (see Notice; separate document) for the same rules regarding use and disclosure of PHI. The law requires that I obtain your signature acknowledging that I have provided you with this information.
Regarding Confidentiality, in most situations the laws provides rules whereby I can only release information about the treatment of a patient, if authorized via a signed authorization form. There are situations that require only advanced consent. Your signature at the end of this agreement provides such consent to the following:
-I may consult with other health and mental health clinicians about your care. All consults are documented in your record.
-If I contract with accountants, lawyers, etc. HIPAA requires a formal contract in which the parties all agree to maintain confidentiality except as specifically allowed.
-Disclosure required by health insurers
-Disclosure needed to collect overdue fees (explained elsewhere).
Also regarding confidentiality, I am permitted and required to disclose information without either your consent or authorization as follows:
-If you are included in a court proceeding, a judge may order the release of a patient’s record.
-If a government agency is requesting the information for health oversight activity.
-If a patient files a complaint or lawsuit against me, I may disclose relevant information for the purposes of a defense.
-If a patient files a Worker’s Compensation claim, I must, upon request, provide appropriate information including a copy of the patient record to the patient’s employer, the insurer, or the Department of Worker’s Compensation.
-In situations of suspected child abuse (under 18), I must notify the Department of Social Services and/or other authorities.
-If I believe an elderly or handicapped individual is suffering from abuse, the law requires me to report to the Department of Elder Affairs.
-If a patient communicates a threat of physical harm to an identifiable victim, the law requires notice to the potential victim, the police, or actions to hospitalize the patient
-If a patient threatens to harm himself/herself, necessary actions to protect the patient must be taken.
All disclosures regarding the above situations are limited to only the minimum necessary information.
Regarding Records, the laws and standards of my profession require that I keep Protected Health Information about you in your Clinical Record. You may examine and/or receive a copy of your records if you request it in writing, unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your records sent to another mental health provider or your attorney. In that these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them in my presence. If I refuse your request for access to your records, you have a right of review, which will be discussed with you upon request.
Regarding the Records of patients under 18 years of age, who are not emancipated, their parents should be aware that the law allows parents to examine their child’s treatment records, unless I believe this would be harmful to the patient and his/her treatment. In that privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment I will provide them only with general information about the progress of the treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless I feel that the child is in danger or is a danger to someone else, in which case I will notify the parents of such. Before giving parents any information, I will discuss the matter with the child, if possible.
Regarding Patient Rights under HIPAA, your rights now include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of disclosures of protected health information that you have neither consented to not authorized; determining the location to which protected information disclosures are sent; having any complaints you make about my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the Notice form, and my policies and procedures regarding Privacy of Patient Records.
C. Paula Krentzel, Ph.D.
223 Walnut Street Suite 20, Framingham, MA 01702
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Date:Authorization to Release or Exchange Information
Name(s): / Date(s) of Birth:I/We (please print) / hereby authorize the exchange of
information between:
AND / C. Paula Krentzel, Ph.D.223 Walnut Street, Suite 20
Framingham, MA 01702
Provider Phone: / Provider Email:
I understand why the information is needed and I am satisfied that the material will be considered confidential. This authorization shall remain in effect until a date or event that I specify here (optional): ______
You have the right to revoke this authorization, in writing, at any time by sending such written notification to my office address. However, your revocation will not be effective to the extent that I have taken action in reliance on the authorization, or if this authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. I also understand that information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
Portion of record to be released or discussed by phone or email:
Medical Record / Psychological Test ReportSchool Record / Summary of contact with individual or family
Other (specify):
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DateSignature of Client / Guardian
C. Paula Krentzel, Ph.D.
223 Walnut Street Suite 20, Framingham, MA 01702
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FEES NOT COVERED BY INSURANCE
The following services are not covered by insurance:
- Appointments canceled with less than 24 hours notice and missed appointments.
- Visits to other agencies, e.g. school visits, conferences at hospital, court appearances.
- Telephone consultations, crisis calls, and telephone calls other than those requested by the individual therapist.
- Letters and reports, e.g. to hospitals, workman’s compensation, agencies, disability forms, information to lawyers requested by you.
I agree to be responsible for fees not covered by insurance, which includes a $120 fee for missed and/or cancelled appointments with less than 24 hours notice.
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Signature of Responsible PartyDate
FINANCIAL AGREEMENT
Insurance payments are accepted per contracted fee schedule.
I will be responsible for co-payments and deductibles established by the insurer.
I agree to have this office submit my claims either electronically or on paper.
I assign payments to this office from my insurer for services rendered to me, or my dependents by C. Paula Krentzel Ph.D.
It is my (client/parent or guardian) responsibility to know my insurance benefits. Therefore, I am responsible for any non-covered services rendered to me or my dependent.
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Signature of Responsible PartyDate
C. Paula Krentzel, Ph.D.
223 Walnut Street Suite 20, Framingham, MA 01702
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FEE SCHEDULE -- As of September 2017
Most fees are covered by your insurance company, except for deductibles and co-pays.
Initial Evaluation$225
Family Therapy (Couples Therapy)$175
Group Therapy (incl Psychoeducational)$60
Individual Therapy 30 minutes$100
Individual Therapy 45 minutes $160
Individual Therapy 60 minutes $200
Cancellations*$120
EMDR (100 minutes)$300
EMDR (50 minutes)$170
Travel – each half hour$80
Report Writing – each 15 minutes$60
Telephone Calls – 15 mins +$60
Telephone Calls – 10 mins or lessNo Charge
*Cancellations: Without 24 hour notice your insurance company does not cover this charge.
Dr. C. Paula Krentzel, Ph.D.
223 Walnut Street Suite 20, Framingham, MA 01702
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SIGNATURE PAGE
I have read and agree to the terms and conditions of Dr. Krentzel’s Patient Services Agreement (“Agreement”) and have been given a copy of Massachusetts Policies and Practices to Protect Privacy (HIPAA) Form.
As stated in the Agreement, I understand and consent to Dr. Krentzel’s submitting necessary information to my insurance company in order to either be reimbursed or to get authorization for treatment.
I have been given a copy of her practice Fee Schedule.
Note to patient: When you sign this page, it represents an agreement between us. You may revoke this agreement at any time in writing. That revocation will be binding on me unless I have taken action in reliance on it; for example, if there are obligations imposed on me by your health insurer in order to substantiate claims made under your policy; or if you have not satisfied any financial obligation you have incurred.
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Signature of Responsible PartyDate
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Client Name (Printed)Date
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