Annette DelCanto-Ellington, LCSW
3530 Bee Cave Road, Suite 211
Austin, Texas 78746
512-426-6889
800-939-2317 (fax)
PROFESSIONAL TREATMENT POLICIES
Session Structure
Therapy sessions are 55 minutes.
Fees
Cost of therapy is $130 per session. If you need a reduced fee, please let me know. I do accept Blue Cross Blue Shield insurance plans.
Late Cancel Fees
If it becomes necessary that you cancel your appointment, please do so with at least 24 hours’ advance notice. Clients will be billed in full for their sessionif cancellation is provided with less than24 hours’ notice. Please note that insurance does not cover missed sessions.
I do allow an exception to late cancel fees. If I have an opening within the same M-F week as the appointment being cancelled and you are able to take that slot, I will waive the late cancel fee. Please be aware, however, that I may not have any other openings for the week, especially if the appointment being cancelled falls late within the week.
Court Testimony
Please note that because I am extremely reluctant to appear in court, as such testimony does not generally benefit the client-therapist relationship,my fee for expert testimony in court or deposition is $750 per hour, beginning when I leave my office to appear in court or deposition, to include all wait time and testimony time, whatever form they may take, and ending when I arrive back at my office. This is a non-negotiable fee. Payment for my fee will proceed as follows: No later than 48 hours prior to my appearance, you will present a credit card to me for payment. Within two days of my appearance, I will present a final bill to you. Within four days of my appearance, I will run the card for my total fee.
Credit and Debit Card Payments
For credit card payments, I use an encrypted, HIPAA approved online credit card system, which will store your card number for convenience. If you choose to use a credit card, please initial here to approve my use of a credit card with which you will provide me to charge for sessions, copays, deductibles, late cancel fees, and any other service you may request of me and that I provide. I accept Visa, Mastercard, American Express, and Discover credit and debit cards.
I approve use of my credit card for the above-stated charges ______
Texting and Emailing
I do send appointment reminders by text or email, and I find emailing and texting to be a convenient way to communicate about logistical issues such as scheduling. However, please know that texting and emailing are not secure methods of communication, and should never be used to discuss counseling issues, and should never contain financial or personal information that would be tempting to identity thieves.
If you choose to text or email me, please be aware that these are not secure methods of communication, and if you are in need of discussing a counseling issue, I will respond to you with a possible time to meet for counseling, or possibly speak by phone.
It is your right to decline correspondence by email or text, including appointment reminders. You may choose to have all outside communication between you and I done by phone. Please indicate which methods of communication you approve by initialing the blank before it.
I approve communication by: ______Text______Email
Medical Care
I recommend that all clients seek medical consultation when experiencing mental health concerns. A medical doctor will be able to assess your physical health and inform you of any physical condition that may be contributing to your current concerns.
Individual Therapy with Children and Adolescents
If therapeutic care is to include counseling with a minor(s), please read and complete the
following information. If not, please mark the section with “N/A”.
_____By initialing to the left, I, the parent or guardian of the below named youth, give
consent for stated minor to participate in counseling sessions with Annette
DelCanto-Ellington, LCSW.
_____By initialing to the left, I, the parent or guardian of the below named youth, give
consent to Annette DelCanto-Ellington, LCSW, or any associate or employee of
Annette DelCanto-Ellington, LCSW, to administer basic first aid techniques in the
event of an accident or injury. In the event of a serious accident, illness, or injury
to my child, and in the event that a parent/guardian or other responsible party
cannot be reached, I authorize Annette DelCanto-Ellington, LCSW, to seek medicalcare on behalf of my minor child.
Name of Minor:______Date of Birth:______
Physician:______Phone:______
Current Medications:______
Current Medical Conditions:______
Annette DelCanto-Ellington, LCSW
3530 Bee Cave Road, Suite 211
Austin, Texas 78746
512-426-6889
800-939-2317 (fax)
______
CONFIDENTIAL CLIENT INFORMATION
Name______Birthdate______Today’s Date______
Address______City/State/Zip______
Home Phone______Work Phone______Cell/Pager______
E-mail______
Employer______
Household Members:Age:Relationship to Client:
What prompted you to seek counseling at this time?
Have you ever had counseling or psychiatric care in the past? If yes, when?
In case of an emergency, please contact:
Is there anything else you would like me to know?
Annette DelCanto-Ellington, LCSW
3530 Bee Cave Road, Suite 211
Austin, Texas 78746
512-426-6889
800-929-2317 (fax)
CLIENT RIGHTS
- Client is entitled to know therapist’s credentials, training and experience.
- Client has the right to ask questions about treatment at any time.
- Client may terminate services at any time.
- Client may refuse treatment, or any part of treatment, at any time.
- Client is entitled to confidentiality about his/her identity and other information shared in sessions. There are, however, special and unusual circumstances in which this right to confidentiality may be waived. They are as follows:
- If I believe client is in imminent danger to him/herself or to others;
- When I am legally required to report abuse or neglect of children, disabled, or elderly persons;
- When client provides written consent to release records and/or information;
- If a court of law orders that I produce a client’s records.
Additionally, at times I may feel it is necessary to consult with a colleague regarding your case in order to provide you with the best possible care. However, if I believe such consultation is necessary and choose to do so, your identity will not be revealed, and I will conceal any possibly identifying characteristics about you. Please inform me if you are uncomfortable with this policy, and do not wish for such consultation to take place.
ACKNOWLEDGEMENT AND AGREEMENT
I have read, understood, and accept the above conditions as set out within the Professional Treatment Policies and Client Rights statements.
CLIENT______DATE______
THERAPIST______DATE______
Annette DelCanto-Ellington, LCSW
3530 Bee Cave Road, Suite 211
Austin, Texas 78746
512-426-6889
800-939-2317 (fax)
INSURANCE INFORMATION
Name of Insurance Plan ______
Subscriber ID No. ______
Group No. ______
Behavioral Health Phone No. (from back of card): ______
If you are not the primary subscriber, please complete the following information as it pertains to the primary subscriber:
Subscriber Name:______
Employer:______
Address:______
Phone No:______
Date of Birth:______
Please read and sign the following for assignment of payment:
I authorize the release of any medical or other information necessary to process this claim. I authorize payment of medical benefits to Annette DelCanto-Ellington, LCSW, for outpatient psychotherapy services.
______
SignatureDate
______
Printed Name
Annette DelCanto-Ellington, LCSW
3530 Bee Cave Road, Suite 211
Austin, Texas 78746
512-426-6889
800-939-2317 (fax)
Health Insurance Portability and Accountability Act (HIPPAA) Notice
This notice describes how psychotherapy and medical information about you may be used and disclosed and how you can get access to the information. Please review it carefully. This information is required under the Health Insurance Portability and Accountability Act (HIPPA) passed by Congress in 1996.
1.Uses and Disclosures for Treatment, Payment and Health Care Operations
Your protected health information (PHI) may be used and/or disclosed for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions.
- PHI refers to information in your health record that could identify you.
- Treatment, Payment and Health Care Operations
-Treatment is when your health care and other services related to your health care are provided or managed. An example of this is consultation with another health care provider, such as your family physician or another mental health professional.
-Payment is being reimbursed for your health care. Examples of payment are when your PHI is disclosed to your health insurance 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 this 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.
- Use applies only to activities within the office, clinic, practice group, etc., such as sharing, employing, applying, utilizing, and examining information that identifies you.
- Disclosure applies to activities outside of the office, clinic, practice, group, etc., such as sending, transferring, or providing access to information about you to other parties.
HIPPA p.2
2.Uses and Disclosures Requiring Authorization
PHI may be used or disclosed for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond course that permits only specific disclosures. In those instances when asked for information for purposes outside of treatment, payment, and health care operations, authorization will be obtained from you before releasing this information. Authorization will also need to be obtained before releasing your psychotherapy notes. Psychotherapy notes are notes created during a private, group, joint, or family counseling session, which are kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.
You may revoke all 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 that authorization has been relied on or if the authorization was obtained as a condition of gaining insurance coverage and the law provides the insurer the right to contest this right under that policy.
3.Uses and Disclosures with neither Consent nor Authorization
PHI may be used or disclosed without your consent or authorization in the following circumstances:
- Child Abuse: If there is cause to believe that a child has been or may be abused, neglected, or sexually abused, a report of such must be made within 48 hours to the Texas Department of Family and Protective Services, the Texas Youth Commission, or to any local or state law enforcement agency.
- Adult and Domestic Abuse: If there is cause to believe that any elderly or disabled person is in a state of abuse, neglect or exploitation, it must immediately be reported such to the Department of Family and Protective Services.
- Health Oversight: If a complaint is filed against treatment staff with any of the applicable State Licensing Boards, they have the authority to subpoena confidential mental health information relevant to that complaint.
- Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law, and the information would not be released without written authorization from you or your personal or legally appointed representatives, or a court order. This 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.
HIPPA p.3
- Serious Threat to Health or Safety: If it is determined that there is a probability of imminent physical injury by you to yourself or others, or there is a probability of immediate mental or emotional injury to you, relevant confidential mental health information may be disclosed to medical or law enforcement personnel.
- Workers Compensation: If you file a worker’s compensation claim, records may be disclosed relating to your diagnosis and treatment to your employer’s insurance carrier.
4.Patient’s Rights and Psychotherapist’s Duties
Patient’s Rights:
- Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of PHI about you. However, agreement to a restriction you request is not required.
- Right to Receive Confidential Communications by Alternative Means and Alternative Locations: You have the right to request and receive confidential communication of PHI by alternative means at alternative locations. For example, you may not want a family member to know that you are being seen. Upon your request, bills or other materials will be sent to another address.
- Right to Inspect and Copy: You have the right to inspect and/or obtain a copy of your PHI and psychotherapy notes in your mental health and billing record. Access to your PHI may be denied under certain circumstances, but in some cases you may have this decision reviewed. On your request, the details of the request and denial process will be discussed with you.
- Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. On your request, the details of the amendment process will be discussed with you.
- Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section 3 of this notice). On your request, the details of this accounting process will be discussed with you.
- Right to Paper Copy: You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.
Psychotherapist’s Duties:
- Treatment staff is required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI.
- Treatment staff reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, treatment staff is required to abide by the terms currently in effect.
HIPPA p.4
- If the policies and procedures are revised, you will be proved with a written copy.
5.Questions and Complaints
If you have questions about this notice, disagree with a decision made about access to your records, or have other concerns about your privacy rights, you may contact treatment staff.
You may send a written complaint to the Secretary of the U.S. Department of Health and Human Services.
You have specific rights under the Privacy Rule. Retaliation against you for exercising your right to file a complaint will not be made.
6.Effective Date of Privacy Policy
This notice will go into effect on February 1, 2010.
I have received a copy of this document:
______
Client SignatureDate