THERAPIST-CLIENTSERVICESAGREEMENT

Thisdocumentcontainsimportantinformationabouttheprofessionalservices andbusinesspoliciesofBowman Counseling & Consulting Services, Inc. (“BCCS”).Italsocontains summaryinformationabouttheHealthInsurancePortabilityandAccountabilityAct(HIPAA)withregardtotheuseand disclosureofyourProtectedHealthInformation(PHI). HIPAArequiresthatyoubeprovidedwithaNoticeofPrivacyPracticesforuseanddisclosureofPHIfortreatment,paymentandhealth care.ThisNoticecanbefoundat A written copy will be provided to you upon request.

The Agreementyouarereadingappliestoyouandyourspecifictherapist and is not an agreement between you and The Indianapolis Gestalt Institute nor is it between you and any other therapist that may work for BCCS.ThelawrequiresthatIobtainyoursignatureacknowledgingthatyouhavebeen providedwiththisinformation.Itis veryimportantthatyoureadthese documents and we discussanyquestionsyouhave.This signed document representsanagreementbetweenus which you may revokeinwritingatanytime.Thatrevocationwillbebindingunlessthereareobligationsimposedbyyourhealthinsurerorifyouhavenotsatisfiedanyfinancialobligationsyouhaveincurred.

PSYCHOLOGICALSERVICES

Ourfirstfewsessionswillinvolveanevaluationofyourneeds,goals,andcircumstances and we will discuss this evaluation.Youshould evaluatethisinformationand decide if youfeelcomfortableworking withme sincetherapyinvolvesalargecommitmentoftime, money,andenergy. Ifyouhavequestionsaboutmyprocedures,weshoulddiscussthemwhenevertheyarise.

THERAPYSESSIONS/MISSEDAPPOINTMENTS

Sessionswillbescheduledatafrequencythatismutuallyagreed upon.Onceanappointmentisscheduled,youwillbeexpectedto payforthefullfeeunlessyouprovide24-hours[1day]advancenoticeofcancellation.Illnesses,accidents,andotherbeyond-our-controlsituationsoccurandwiththeseevents,therewillbenochargeformissedorcancelledappointments.Itis importanttonotethatinsurancecompaniesdonotprovidereimbursementforcancelled ormissedsessions.

EMERGENCYPROCEDURES

Iamnotavailable24-hours orduringweekends/holidays. Ifan emergencyoccurs,pleasedial911orsafely proceed to the nearest emergency room.CallmeandleaveamessagesothatIknowwhatishappeningandcangetintouchwithyouassoonas possible.

LIMITSONCONFIDENTIALITY

Thelawprotectstheprivacyofallcommunicationsbetweenaclientandapsychotherapist.Inmostsituations,Icanonlyreleaseinformationaboutyourtreatmenttoothersifyousignawritten release of informationthatmeetscertainlegalrequirementsimposedbyHIPAA.Thereareothersituationsthatrequireonlythatyouprovidewritten,advanceconsent.YoursignatureonthisAgreementprovidesconsentforthoseactivities,asfollows:

  1. Professional consultation withotherhealthprofessionals.Iwillnotrevealyouridentity and they, too, arelegallyboundtokeeptheinformationconfidential.Iwillnottellyouabouttheseconsultationsunlessitisimportanttoourworktogether or if you inquire.
  2. TherearesomesituationswhereIampermittedorrequiredtodiscloseinformationwithouteitheryourconsentorauthorization. These situations include, but are not limited to, the following:
  3. Courtproceedings requesting information.Icannotprovideitwithoutyour(oryourlegalrepresentative’s)writtenauthorizationoracourtorder.
  4. Complaintsorlawsuitsrequiring metodefendmyself.
  5. Ifyouthreatenseriousharm toyourself or others,Imayseekhospitalization,contactfamilymembers, law enforcementortake other steps necessary to provide protection.
  6. If I have reason to believe that a child vulnerableadulthas been or is likely to be subjectedphysical abuse, neglect, sexual exploitationabuse, the law requiresthatIimmediatelynotifytheDivisionofChildServices, Adult Protective Services,oran appropriatelawenforcementagency.Oncesuchareportisfiled,Imayberequiredtoprovideadditionalinformation.

If one of thesesituationsarises,Iwillmakeeveryefforttofullydiscussmy actionswithyoubeforeproceedingandIwilllimitmydisclosuretowhatisnecessary.Thelawsgoverningconfidentialitycanbequitecomplex,andIamnotan attorney.Insituationswherespecificadviceisrequired you may wish to seekformallegaladvice.

PROFESSIONALRECORDS

YoushouldbeawarethattheProtectedHealthInformation(PHI)I keep includesprogress notes, yourdiagnosis,goals,your medical,social, and treatmenthistory,and past treatment records. Your PHI also includes yourbillingrecordsandanyreports thathavebeensenttoanyone.

Exceptinunusualcircumstancesthatinvolvedangertoyourselfand/orothersorwhereinformationhasbeensuppliedtomeconfidentiallybyothers,youmayexamineand/orreceiveacopyofyourClinicalRecord,ifyourequestitinwriting.Generally, I respondtorequestsforClinicalRecordsonlywithatreatmentsummary. IfyoudowanttoseeyourClinicalRecords,IrecommendthatyoureviewtheminmypresenceIwouldconductanyreviewmeetingwithournormalfeecharge.HIPAAprovidesyouwithrightstoyourClinicalRecordanddisclosuresofPHI.TheserightsincluderequestingthatIamendyourrecord;requestingrestrictionson whatinformationfromyourClinicalRecordisdisclosedtoothers;requestinganaccountingof mostdisclosuresofPHIthatyouhaveneitherconsentedtonor authorized;determiningthelocationtowhichprotectedinformationdisclosuresaresent;and havinganycomplaintsyoumake, and aboutmypoliciesandproceduresrecordedinyourrecords.

MINORS PARENTS

If you are under eighteen years of age, please be aware that while the specific content of our communications is confidential, your parents have a right to receive general information on the progress of the treatment. Under current Indiana law, in group and family therapy and in marital therapy all participants are required to consent to the release of information. One marital partner may not waive privilege for another. In cases of marital therapy, therefore, the record may be released only if both parties waive privilege or release of the record is court ordered.

PROFESSIONALFEES

My fee for individual psychotherapy begins at $110 per hour. Longer sessions are prorated from this basic fee. The same fee applies for other professional services you may require, such as reading or writing reports, or off-site travel. My fee for group therapy varies. Contact me to discuss the appropriateness of group therapy and the cost.

Ifyoubecomeinvolvedinlegalproceedingsthatrequiremyparticipation,youwillbeexpectedtopayforallofmyprofessionaltime,including preparationandtransportationcosts,evenifIamcalledtotestifybyanother party. Becauseofthedifficultyoflegalinvolvement,Icharge$250perhourforpreparationandattendanceatanylegalproceeding.

BILLINGANDPAYMENTS

Payment is due at the time services are rendered unless we make other arrangements. I “accept assignment,” that is, collect co-payments and bill insurance companies for the balance due. Check with your carrier about coverage before starting therapy.I accept cash, check or credit card payment at the time of service.

Youwillbeexpectedtopayforeachsessioninfullunlessweagreeotherwiseorunlessyour insurancecoveragerequiresanotherarrangement.Anannualfinancechargeof17.5%willaccrueonallunpaidaccountsunlessspecificpaymentarrangementshavebeensetupbetweenus.Ifyouraccounthasnotbeenpaidformorethan60 daysandarrangementsforpaymenthavenotbeenagreedupon,Ihavetheoptionofusinglegalmeanstosecurethepayment.Thismayinvolvehiringan attorney,collectionsagency, and/orgoingthroughsmall claimscourt,whichwillinvolve disclosingotherwiseconfidentialinformation.Ifsuchlegalactionisnecessary,you are responsible for thecosts I incur, including attorney’s fees.

INSURANCEREIMBURSEMENT

Healthinsurancepolicies generallyprovidesomecoverageformentalhealthtreatment whether I am a memberofyourinsurance panel oran“outofnetworkprovider.”Iwillforms orprovideyouwith whateverassistanceIcaninhelpingyoureceivethebenefitstowhichyouareentitled, but you(notyourinsurancecompany)areresponsibleforpaymentofmyfees.Insurancebenefitsarecomplex and it is oftendifficulttodeterminecoverage.Ifyouhavequestionsaboutyourinsurancecoverage,callyourplanadministrator.

Ifyoudecidetoseekthird-partyreimbursement,I willprovideyour insurance company relevantinformation in order for them to process the claim. Ifyouchoosetouseyourinsurance,thensomeofthepotentialconsequencesto consideristhatthisuseanddiagnosismayaffectapplyingforhealth,life,ordisabilityinsuranceinthefuture.Iwillmakeeveryefforttoreleaseonlytheminimuminformationaboutyouthatisnecessaryforthepurposerequested.Although HIPAAprovidesageneralframeworktoprotectclientconfidentiality,therearemanywaysinwhichyourelinquishmanyofyourrightstoprivacywhenyouparticipateinthirdpartyreimbursement and I have no control over the information once it is released

BysigningthisAgreement,youagreethatIcanproviderequestedinformationtoyourcarrierifyouareusingthirdpartyreimbursement.Itisimportanttorememberthatyoualwayshavetherighttopayformyservicesyourselfto avoidtheproblemsdescribedabove.Ifyourtherapyisself-payyoumaintainmaximumcontroloveryourrecord.

Yoursignaturebelowindicatesthatyouhavereadthisagreementandagreeto itstermsandalsoservesasanacknowledgementthatyouhavereceivedtheHIPPAnoticedescribedabove or know where to obtain it on my website.

HIPAAPRIVACY POLICY DISCUSSED ANDRECEIVED IF REQUESTED:

Signature (Parent or Guardian if Minor)Date

Signature (Parent or Guardian if Minor)Date

AGREEMENTREADUNDERSTOOD:

Signature (Parent or Guardian if Minor)Date

Signature (Parent or Guardian if Minor)Date

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Charles Bowman, MS, LCSW, LMFT, LCAC

NPI 1568670404

TID 351983108