Cynthia Chioco, Psy.D.
Oakview Professional Pointe
3917-A East Memorial Road
Edmond, Oklahoma 73013
Telephone: 405.326.4599
INFORMATION FOR NEW CLIENTS
Welcome to my practice. Please take the time to read all of the following information. I am happy to discuss any questions you may have at our next meeting.
TRAINING AND LICENSURE: I earned my Doctor of Psychology (Psy.D.) degree from Baylor University. I received specialized training to work with children, adolescents and their families from the Medical College of Virginia – Virginia Treatment Center for Children. There, I completed an APA approved, two-year internship and residency program in clinical psychology. I also have extensive training and experience in working with adults. Since 1992, I have been licensed to practice in the state of Oklahoma. I have been a member of the American Psychological Association (APA) since 1987. If you have any questions regarding my education, training and experience, please ask at any time and I will gladly answer them.
CONSULTATIONS: You are entitled to seek another professional’s opinion or talk to another therapist at any time. I am happy to help you find a qualified clinician and, with your written permission, will provide him/her with the needed information.
If you could benefit from treatment I am unable to provide, I will help you to get it. You have a right to ask about other treatments, their benefits and risks. If appropriate, I may recommend a medical exam or use of medication. I may need to consult with your/your child’s primary care physician for evaluation or prescribing of medication. Before doing so, I will discuss my reasons with you so you can decide what is best. When appropriate, I will make every effort to coordinate my services with other professionals from whom you are receiving treatment.
CONFIDENTIALITY: All the information you share with me, as well as test results, notes and records, is confidential and will not be revealed to any outside person or agency without your written permission. Exceptions to this are:
- if it is legally required, such as in cases of court-ordered evaluations or treatment
- if you make a serious threat to harm yourself or another person
- if I believe a child, handicapped individual, or an elderly person has been or will be abused or neglected
- if you report sexual exploitation by a therapist or other clinician
The rules of my profession, as well as state law mandates that I, as a mental health professional, may need to report any of the above situations to the appropriate persons and/or agencies.
There are two situations in which I may share part of your case with another therapist. First, when I am away from the office for several days, I arrange for a trusted fellow therapist (usually, another clinician in this office) to “cover” for me in cases of emergency or crisis. Therefore, I will only provide enough information to her or him about you and your situation to handle the emergency or crisis effectively. Of course, the same rules and laws apply to this therapist, as they do with me. Second, in an effort to provide quality of care, I may occasionally consult with other therapists or professionals about my clients. They are also required to keep your information confidential. Your name will never be given to them, and they will be told only as much as they need to know to understand your situation.
All office staff members are trained in making every effort to keep the names and records of clients private. Your records will not be released to anyone else, including other professionals, without your written consent.
Generally, your health insurance company will receive only my statement, which provides dates of service, my charges, and a diagnosis. As part of cost control efforts, however, it is becoming standard practice for insurance companies to ask for information on symptoms, diagnoses, and my treatment methods. Please understand that I have no control over how these records are handled at the insurance company. My policy is to provide only as much information as the insurance company requires to pay your benefits.
APPOINTMENTS: I typically schedule one (1) hour for our initial meeting as there is a great deal of information to be exchanged. Thereafter, individual appointments are generally fifty-five (55) minutes in length and held exclusively for you, your child, and/or family. An appointment is a commitment to our work. We agree to meet on time. I ask for your understanding if I am unable to start on time. I will make every effort, however, to ensure that you receive your full time. If you are late, we will probably not be able to meet for the full time as I am likely to have another appointment following yours. If, for any reason, you are unable to keep your appointment, please notify my office at least twenty-four (24) hours in advance. Otherwise, you will be charged half of my fee for the first missed appointment and the full amount for appointments missed thereafter. Insurance companies reimburse for services rendered; therefore, charges for missed appointments or late cancellations will not be billed to an insurance company. It is the client’s responsibility to pay for the missed appointment. Delinquent accounts will be sent to the credit bureau.
FEES, PAYMENTS AND BILLING: The initial evaluation is charged at $170.00.Your fee per individual session is $150.00. Couples/marital therapy and family sessions are charged at $160.00. Sessions are 55 minutes unless otherwise agreed upon. Fees are subject to change every six months. If there is a change, you will be given advance notice. Payment is expected to be made in full for services at the time they are rendered. In those instances in which I have a preferred provider relationship, you will be asked to make your deductibles, when due, and co-payment at the time of service. We do not charge you any fee for filing your insurance. Please understand that you, the client, are fully responsible for the payment of all fees for services provided, regardless of the extent of any insurance coverage you may have. It is the policy of this office to turn seriously delinquent accounts over to the credit bureau. Only information that is non-clinical in nature will be given to the collection agency and/or credit bureau.
Charges for other professional services which you authorize, such as consultations with other therapists; hospital visits; phone contacts (over 10 minutes); preparation of special forms, reports or letters; home visits, and travel time will be billed at your agreed upon fee above, per quarter hour increments. Court-related services, such as depositions or expert witness testimony are billed at a different rate. Please let me know if you will require these services. We can discuss the fees and financial arrangement. Some services may require payment in advance.
INSURANCE COVERAGE AND REIMBURSEMENT: As a licensed psychologist, my services for evaluation and psychotherapy are partially reimbursed under several insurance plans. Payment is expected at the time of service. If you belong to a particular HMO, PPO, or any other managed health care program, you should be aware of all rules, limitations and procedures they require. It is your responsibility to discuss the behavioral health services offered under your plan with your case manager and, if required, obtain permission to be treated or seek initial consultation prior to our first meeting. Every effort will be made by this office to facilitate the payment of benefits to which the insured is entitled. I ask that you provide your insurance card at your first visit to allow my office staff to verify your benefits. The office should be informed as soon as possible of any change in address or changes regarding your insurance company or policy.
If you belong to a health maintenance organization (HMO) or have another kind of health insurance with managed care, decisions about what kind of care you need and how much of it you can receive will be reviewed by their plan. The plan has rules, limits, and procedures with which you should be familiar. In order to help you with any health insurance benefits, I will have to send information about you to your managed care company or to any agent of your insurance company. These companies are increasingly asking for more information about clients and may want to know about your problems, symptoms, family and work life, and so forth. The staff of the insurance and managed care companies, and possibly of your employer will review this information. These individuals do not have the same training in maintaining confidentiality as do mental health professionals. You may want to keep this in mind when deciding whether or not you will use your mental health insurance benefits. Information to insurance companies is typically sent by fax or mail.
TELEPHONE AND EMERGENCY CALLS: I am in the office Wednesday and Thursday, 9am to 6pm and Friday, 9am to 5pm. Please feel free to contact me during my regular business hours. I will make every effort to take your call if I am not with another client. In this event, please leave a message on my private cell phone or with my office staff, and I will return your call as soon as I can. Generally, I return calls within 24 to 48 hours.
If you have an emergency or are in crisis, please contact me. If your emergency occurs outside of my regular business hours and you are unable to reach me, call or go to the nearest hospital emergency room.
AGREEMENT: I, the client (parent or guardian, if a minor) understand I have the right not to sign this form. I understand I can discuss my concerns with Dr. Cynthia Chioco before I (or my child) begin(s) therapy. If, at any time during treatment, I have questions about any of the subjects discussed above, I may talk with Dr. Chioco about them.
I understand that after therapy begins, I have the right to withdraw my consent for treatment at any time for any reason. I will, however, make every effort to discuss my concerns about my (or my child’s) progress with Dr. Chioco before ending therapy.
I have accepted this document entitled INFORMATION FOR NEW CLIENTS and intend to read it or have it read to me. If there are points I do not understand, I will ask questions at my next visit. I agree to (or have my child) enter into therapy with Dr. Chioco, and to cooperate fully with the provisions of this document.
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Signature of Client or Parent/Legal Guardian (if a minor)Date
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Printed Name of Client
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Printed Name of Parent/Legal Guardian and Relationship to Client
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Cynthia Chioco, Psy.D.Date
CYNTHIA CHIOCO, PSY.D.
Licensed Psychologist
Oakview Professional Pointe · 3917-A East Memorial Road · Edmond, Oklahoma 73013 · Phone: 405.326.4599
CONSENT FOR TREATMENT: CHILD/ADOLESCENT
Client’s
Initials
Therapy sessions and file information are confidential.
Except in cases of: 1) court orders/subpoenas, 2) to defend legal actions against Cynthia Chioco, Psy.D., 3) need to
prevent harm to self or others, and 4) suspected child abuse or neglect. Third party billing and lawsuits I bring related
to mental health issues may also limit the confidentiality of my file. _____
There are some limitations to my access to my child’s file.
I understand that confidentiality is very important to my child’s ability to use therapy. While I have the right to access my
child’s file, I understand that doing so may jeopardize the therapeutic process. I agree to consult with my therapist about
any questions I have concerning the content of my child’s file or sessions. _____
I must sign a release form before information can be exchanged with other agencies.
The privacy of any electronic communication cannot be assured. Do not use email for urgent matters. I may request
restrictions on the use/disclosure of information in my child’s file for treatment, payment and healthcare operations, but
my child’s therapist is not required to agree with my request. _____
Some information from my child’s file may be used for research purposes.
I understand that my child’s name or any other identifying information will not be used in research. _____
Cynthia Chioco, Psy.D. does not provide after-hours or emergency services.
I will use 911 for after-hours crises. _____
The practice of psychology and related disciplines is not an exact science.
No guarantees have been made to me regarding the results of services provided to me by Dr. Cynthia Chioco. I am
responsible for working with my child’s therapist to help ensure better treatment outcomes. _____
Cynthia Chioco, Psy.D. is not a medical doctor and cannot prescribe medications. _____
I consent to or my child or myself to undergo all recommended testing and/or treatment procedures.
I can refuse or discontinue testing and/or treatment for my child or myself at any time. _____
I agree to pay for services rendered to my child. Payment is due at the beginning of sessions and I must cancel
at least 24 hours before my child’s session or I am responsible for the cost of the session.
Consequences of non-payment may include termination of services and/or being referred to a collection agency/
attorney for all unpaid account balances. _____
Special payment/reporting arrangements may be made in cases of divorce and court-mandated services. _____
I acknowledge that my child’s therapist has given me the General Consent for Treatment form, that I have read it, been given the opportunity to ask questions and given a copy to keep for my records.
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Signature or Therapist or Witness Date
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Printed Name of Guardian/Legal Representative
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Signature of Guardian/Legal Representative Date
CYNTHIA CHIOCO, PSY.D.
Licensed Psychologist
Oakview Professional Pointe · 3917-A East Memorial Road · Edmond, Oklahoma 73013 · Phone: 405.326.4599
AGREEMENT TO PAY FOR PROFESSIONAL SERVICES
I, the client (or legal guardian/representative), request that Cynthia Chioco, Psy.D. provide professional services to me or to ______, who is my ______. I agree to pay Dr. Chioco’s fee of $170.00 for the initial evaluation, $150.00 for 55/60-minute individual therapy sessions, and/or $160.00 for couples/family therapy sessions. These fees will apply unless otherwise negotiated in writing.
I agree that this financial relationship with Dr. Chioco will continue as long as she provides services or until I inform her, in person or by certified mail, that I wish to end it. I agree to meet with Dr. Chioco at least once before stopping therapy. I agree to pay for services provided to me (or this client) until the time I end the therapeutic relationship.
I understand that if I do not pay for services, Dr. Chioco may terminate the services provided. Continued non-payment of fees may result in further consequences such as my account being referred to a collection agency.
I agree that I am responsible for the charges for services provided by Dr. Chioco to me (or this client), although other persons or insurance companies may make payments on my (or this client’s) account. If any portion of my fees is being paid by an insurance company or other third party payer, I understand that this may result in limitations to my confidentiality.
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Signature of Client or Legal Guardian/Representative Date
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Printed Name of Client or Legal Guardian/Representative
I, Dr. Chioco, have discussed the issues above with the client (and/or person acting on behalf of the client). My observations of this individual’s behavior and responses give me no reason to believe that s/he is not fully competent to give informed and willing consent.
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Signature of Therapist Date
Copy accepted by client
Copy kept by therapist
HIPAA Notice of Privacy Practices
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Cynthia Chioco, Psy.D.
Oakview Professional Pointe
3917-A East Memorial Road
Edmond, OK 73013
405.326.4599
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
1. Uses and Disclosures of Protected Health Information (PHI)
Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
You will be asked to sign a consent form. Once you have consented to the use and disclosure of your/your child’s PHI for treatment by signing the consent form, I will use or disclose your PHI as described below:
Treatment: I will use and disclose your/your child’s PHI to provide, coordinate or manage your/your child’s healthcare and any related services.
Healthcare Operations: I may use and disclose, as needed, your PHI in order to support the business activities of my practice. These activities include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of mental healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation certification, licensing or credentialing activities, and conducting or arranging for other business activities.
Emergencies: I may use or disclose your/your child’s PHI in an emergency treatment situation. In the event of your/your child’s incapacity or emergency circumstances, I will disclose healthcare information based on determination using my professional judgment, disclosing only health information that is directly relevant to the person’s involvement in your/your child’s healthcare.
Other uses and disclosures of your/your child’s PHI will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you provide a written authorization, I cannot use or disclose your/your child’s health information for any reason except those described in the notice.
Other Permitted and Required Uses and Disclosures That My Be Made Without Your Consent, Authorization or Opportunity to Object
I may use of disclose your/your child’s PHI in the following situations without your consent or authorization:
Required by Law: I may use or disclose your/your child’s PHI to the extent that law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirement of the law.
Health Oversight: I may disclose your/your child’s PHI to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.
Abuse or Neglect: I may disclose your/your child’s PHI to the Department of Human Services, which is authorized by law to receive reports of child abuse or neglect. In addition, I may disclose your/your child’s PHI if I believe that you/your child have/has been a victim of abuse or neglect to the Department of Human Services. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.