Douglas M. Buyer, Ph.D., LLC

Douglas M. Buyer, Ph.D., LLC

Psychologist

An Independent Practice

______1438 West 38th Street Phone: 814-315-4054

Erie, PA 16508 Fax: 814-281-3061

Fax: 814-555-5555

Welcome,

I am looking forward to working with you. With your assistance and cooperation I will do my best to provide you services in a positive and safe environment. Please be aware that my office is not wheelchair accessible. If you need wheelchair accessibility I will make special arrangements to meet elsewhere.

Please read the following information and complete pages 4 and 5.

Confidentiality:

Issues discussed in therapy are important and are generally legally protected as both confidential and “privileged”. However, there are limits to the privilege of confidentiality. These situations include:

1. Suspected abuse or neglect of a child, elderly person or disabled person

2. When your psychologist believes you are in danger or harming yourself or another person or you are unable to care for yourself

3. If you report that you intend to physically injure someone the law requires me, as the psychologist to inform that person as well as the legal authorities

4. If I, as the psychologist, am ordered by a court to release information as part of a legal involvement in litigation

5. When your insurance company is involved, e.g. filing a claim, insurance audits, case review or appeals

6. Innatural disasters whereby protected records may become exposed

7. When otherwise required by law

You may be asked to sign a Release of Information so that we may speak with other health professionals or family members.

Record Keeping:

A clinical chart is maintained describing your condition, your treatment, progress in treatment, dates and fees for sessions, and notes describing each therapy session. Your records will not be released without your written consent, unless in those situations outlined in the confidentiality section above. Medical records are kept locked.

Payments:

Payment is due at the time of the session unless other arrangements have been made. We will file your insurance claim, but you are responsible for any deductibles, co-insurance, and co-pays. It is your responsibility to familiarize yourself with your insurance benefits as well as to inform us if there are any changes to your policy during your treatment period.

Cancellations and Missed Appointments:

You will be charged for a session that you cancel with less than 24 hours’ notice. You may leave messages 24 hours per day; however you may not cancel via email! You will be billed $50.00. Insurance companies do not reimburse for failed appointments. If you have not called to cancel your appointment and do not show up for the appointment, we reserve the right to cancel any further appointments that have been scheduled. **After two no shows in one treatment period, the policy is to discontinue services.

HIPPA NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESSS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective date: January 1, 2014

DR. DOUGLAS M. BUYER PHD, LLC has been and will always be committed to maintaining client’s confidentiality. I will only release healthcare information about you in accordance with federal and state laws and ethics of the profession of psychology.

This notice describes my policies related to the use and disclosure of your healthcare information.

Uses and disclosures of your health information for the purposes of providing services. Providing treatment services, collecting payment and conducting healthcare operations are necessary activities for quality care. State and federal laws allow me to use and disclose your health information for these purposes.

TREATMENT: I may need to use or disclose health information about you to provide, manage, or coordinate your care or related services, which could include consultants and potential referral sources.

PAYMENT: Information needed to verify insurance coverage and/or benefits with your insurance carrier, to process your claims as well as information needed for billing and collection purposes. I may bill the person in your family who pays for your insurance.

HEALTHCARE OPERATIONS: I may need to use information about you to review our treatment procedures and business activity. Information may be used for certification, compliance and licensing activities.

Other uses or disclosures of your information which does not require your consent.

There are some instances where I may be required to use and disclose information without your consent. For example, but not limited to: Information you and/or child or children report about physical or sexual abuse: then by Pennsylvania State Law, I am obligated to report this to the Department of Public Welfare; if you provide information that informs me that you are in danger of harming yourself or others; information to remind you of/or to reschedule appointments or treatment alternatives; information shared with law enforcement if a crime is committed on my premises or against me or other staff as required by law such as a subpoena or court order.

INFORMED CONSENT TO TREAT

As the client or authorized representative, I consent to the rendering of counseling treatment and/or testing on an outpatient basis. I further understand that I may withdraw from treatment at any time.

I understand that all information regarding my treatment is confidential and will not be released unless:

1. It is authorized in writing.
2. It is ordered by the court system to do so.
3. Abuse or neglect is suspected.
4. Threat of physical danger to anyone (including client) is suspected.
5. Request of funding sources or auditors who have a legitimate need to review chart. Also included information to insurance companies regarding filing a claim.
6. In natural disasters whereby protected records may become exposed.

This consent will remain in effect until the time that I have been discharged. I have read the above information regarding my treatment and I am in agreement to it.

CLIENT RIGHTS

Right to release your medical records

You may consent in writing to release your records to others. You have the right to revoke this authorization, in writing, at any time. However, a revocation is not valid to the extent that we acted in reliance on such authorization.

Right to request a copy of your billing records

You have the right to inspect and obtain a copy of your billing information contained in my records. Under limited circumstance, I may deny your request to inspect and copy. If you ask for a copy of any information, I may charge a reasonable fee for the costs of copying, mailing and supplies.

Right to add information or amend your medical records

If you feel that the information contained in your medical record is incorrect or incomplete, you may ask me to add information to amend the record. I will make a decision on your request within 60 days, or some cases within 90 days. Under certain circumstances, I may deny your request to add or amend information. If I deny your request, you have a right to file a statement that you disagree. Your statement and my response will be added to your record. We will require you to submit your request in writing and to provide an explanation concerning the reason for your request.

Right to an accounting of disclosures

You may request an accounting of any disclosures, if any, I have made related to your medical information, except for information I used for treatment, payment, or health care operational purposes or that I shared with you or your family, or information that you gave me specific consent to release. It also excludes information that I was required to release. To receive information regarding disclosure made for a specific time period no longer than six years and after April 14, 2003, please submits your request in writing to my office. I will notify you of the cost involved in preparing this list.

Right to request restrictions on uses and disclosures of your health information.

You have the right to ask for restrictions on certain uses and disclosures of your health information. This request must be in writing and submitted to my office. However, I am not required to agree to such a request.

Right to complain.

If you believe your privacy rights have been violated, please contact me personally, and discuss your concerns. If you are not satisfied with the outcome, you may file a written complaint with the U.S. Department of Health and Human Services. An individual will not be retaliated against for filing such a complaint.

Right to receive changes in policy.

You have the right to receive any future policy changes secondary to changes in state and federal laws. This can be obtained from my office.

Authorization to Exchange Information with Primary Care Physician

I understand that my records are protected under the applicable state laws governing health care information that relates to mental health services and cannot be disclosed without written consent unless otherwise provided for in state or federal regulation. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This release will remain in effect for one year from date of signature. I hereby authorizeDr. Douglas M. Buyer PhD, LLC to exchangeinformation with my Primary Care Physician listed on page 4 for the purpose of coordinating my care.

CLIENTS NAME:

D.O.B:GENDER: M/F

ADDRESS:

CITY:STATE:ZIP:

HOME PHONE:CELL PHONE:

WORK PHONE:EMAIL ADDRESS:

SCHOOL NAME:

CLIENT’S CONTACT PERSON:

RELATIONSHIP TO CLIENT:

HOME PHONE:CELL PHONE:

FAMILY PHYSICIAN:

ADDRESS:

CITY:STATE:ZIP:

PHONE NUMBER:

INSURANCE INFORMATION

PRIMARY INSURANCE:

POLICY HOLDER’S NAME:D.O.B:

RELATIONSHIP TO CLIENT:

MEMBERSHIP ID# GROUP #

SECONDARY INSURANCE:

POLICY HOLDER’S NAME:D.O.B:

RELATIONSHIP TO CLIENT:

MEMBERSHIP ID# GROUP #

I understand that my insurance information will be used to bill my insurance company.I have provided the most accurate information possible. I authorize the release of any medical information necessary to process insurance claims and request payment of insurance benefits to be made directly to Douglas M. Buyer, PhD., LLC. I understand I am financially responsible for all charges if they are not covered by my insurance.

****I have read and consent to the following information: (Please check off each one)

_____Welcome Information

_____HIPPA Notice

_____Informed Consent to Treat

_____Client Rights

_____Authorization to Exchange information with the Family Physician

_____Insurance Information Page (I have provided information to the best of my knowledge)

I give my permission to be contacted at the following telephone number(s)and to leave a message with the following information. (Please specify whether number is home, cell, work, or other.)

______

___ Name of Caller and Affiliation___Other

___ Appointment Date and Time___ Any Information

______

Signature of Patient age 14 and over Date

______

Print Name

______Signature of Parent or Guardian (if applicable) Date

______

Print NameWitness initials

We will provide you copies of any of the information in this packet with a verbal request.

Intake Packet as of 1/1/2014

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