NV PSYCH DOC, LLC.
Dr. Kriston A Segura
Clinical Psychologist NVPY0416
2110 East Flamingo Road, Suite # 317, Las Vegas, Nevada 89119
Phone: 702-308-5114Fax:702-410-8401
Consent for Treatment Form
OUTPATIENT SERVICES CONTRACT
Welcome to Dr. Segura’s Practice – NV PSYCH DOC, LLC. Our providers are governed by various laws and regulations and by the codes of ethics of their respective professions. The ethics code requires that we make you aware of specific office policies and how these procedures may impact you. This document contains important information about our professional services and business policies. Please read it carefully and jot down any questions you might have so that you and your provider can discuss them at your next meeting. When you sign this document, it will represent an agreement between you and The Practice.
COUNSELING SERVICES
Psychotherapy is not easily described in general statements. It varies depending on the personalities of the therapist and client, and the particular problems you bring forward. There are many different methods that a provider may useto deal with the problems that you hope to address. Our providers have been trained in methods that are evidence based and supported by research. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for therapy to be most successful, you will have to work on things discussed both during your sessions and at home.
Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. Sometimes counseling services are provided primarily to prevent further deterioration of your mental or emotional status, which is considered maintenance treatment.
Your first few sessions will involve an evaluation of your needs. By the end of the evaluation, your provider will be able to offer you some first impressions of what your work will include and a treatment plan to follow, if you decide to continue with therapy. Under certain circumstances you may be referred for a psychiatric consult; psychological testing; conjoint marital/couple, conjoint parent/child sessions, and/or group psychotherapy. Therapy involves a large commitment of time, moneyand energy, so you should be very careful about the therapist you select. If you have questions about methods, you should discuss them whenever they arise. If your doubts persist, we would be happy to refer you to another mental health professional for a second opinion.
Thank you and we look forward to working with you.
¹ NV PSYCH DOC, LLC. Is a Nevada corporation that represents Dr. Kriston A Segura—clinical psychologist.
FINANCIALPOLICY
IunderstanditisthepolicyofThe Practicetorequirepaymentfor servicesrenderedatthetimeofthevisit.Iagreetobefinanciallyresponsibleforallchargesandpayforallservices,whetherornottheyarecoveredbymyinsurance.Fees start at $250.00for an initial assessment. Individual and couple therapy sessions are $165.00 and $150.00 for a 60 minute and 45 minute session respectively. Fees for psychological and bariatric testing vary depending on the test being performed.Seeadditionalfeescaleforotherservices,such asattendanceatIEPmeetings,courtrelatedservices,andlettersor reportsonyourbehalf.
Iunderstandthatforinsuranceclaims,The NV PSYCH DOC, LLCwillsubmitaclaimto myinsurance companyasacourtesy,but the submission of the claim is not a guarantee ofpayment.I understandIamresponsiblefinanciallyforanyunpaidclaimsanditismyresponsibility toverifymycoveragedirectlywithmyinsurancecarrier. In addition, I understand that NV PSYCH DOC, LLCis contractually obligated to collect all appropriate co-pays and/or co-insurance or they will be in violation of their provider contract and my claim may be denied as a result.Iunderstandmysignatureauthorizes the release of medical information to my insurance company that may be necessary to process the claim and thatpayment from my insurance company is made directly to NV PSYCH DOC, LLC.If a secondaryinsurance payerisindicatedinbox9aoftheCMS1500formorelsewhereonan electronicallysubmittedclaim,mysignatureauthorizesreleaseofinformationtotheinsureroragencyshown.
IunderstandIwillincurachargeof$50.00foranyreturnedcheck and afee of$50.00the first time an appointmentis cancelledwithout24hournotice,or if I fail to come to a scheduled session. After the first time, and any time thereafter, I will be billed the full charge of $150 for any missed appointments.NV PSYCH DOC, LLCisboundbytheethicscodetoapplypoliciesto allclients;therefore,noexceptionsorwaiverstothispolicywillbemadeunless documentationofanemergencycanbeprovided.
Ihaveread,acknowledge,andagreetotheabovestatedterms.MyauthorizationwillremaininfullforceandeffectuntilIrevokeitinwriting.
ResponsibleParty SignatureDate
1 | Page NV PSYCH DOC, LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401
AdditionalFees
Service: Fees:
ExtendedPhoneCalls(15minutesormore)Billed at standard session rates
Paperworkcompletedoutsideofsession
(e.g.,forschool,employers,FMLA)$25.00
LettersorReportsofTherapeuticProgress$50.00
AttendanceatSchoolorIEPmeetings$200.00/hr.
Deposition/Affidavits(inpsychologists’office)$250.00/hr.
CourtAppearance$800.00/4hours
(Minimum4hours)
Bariatric Surgery Evaluation$525 (unless otherwise negotiated/cash rate)
PsychologicalTesting
*Pleasenote:
FeesaredueinadvanceforattendanceatschoolorIEPmeetings,depositions,andcourtappearances.Allotherfeesaredueatthetimeofservice.
Wedonotbillinsurancecompaniesfortheseservices(exceptforPsychologicalTesting).
We would behappytoprovideanyinformationyourequiresothatyoumayseekreimbursementfromyourinsurance.
ResponsiblePartySignature Date
1 | Page NV PSYCH DOC LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401
NoticeofPrivacyPractices
THISNOTICEDESCRIBESHOWMEDICALINFORMATIONABOUTYOUMAYBEUSEDANDDISCLOSEDANDHOWYOUCANGETACCESSTOTHISINFORMATION. PLEASEREVIEWTHISNOTICECAREFULLY.
Yourhealthrecordcontainspersonalinformationaboutyouandyourhealth.Thisinformation, whichmayidentifyyouandrelatestoyourpast,present,andfuturephysicalormentalhealthconditionandrelatedhealthcareservices,isreferredtoasProtectedHealthInformation(PHI). ThisNoticeofPrivacyPracticesdescribeshowThe PracticemayuseanddiscloseyourPHIinaccordancewithapplicablelaw.ItalsodescribesyourrightsregardinghowyoumaygainaccesstoandcontrolyourPHI.
We arerequiredbylawtomaintaintheprivacyofPHIandtoprovideyouwithnoticeofourlegal dutiesandprivacypracticeswithrespecttoPHI.We arerequiredtoabidebythetermsofthisNoticeofPrivacyPractices. We reservetherighttochangethetermsoftheNoticeofPrivacyPracticesatanytime.WewillprovideyouwithacopyoftherevisedNoticeofPrivacyPracticesbypostingacopyonourwebsite,sendingacopytoyouinthemailuponrequest,orprovidingonetoyouatyournext appointment.
HOWWEMAYUSEANDDISCLOSEHEALTHINFORMATIONABOUTYOU:
ForTreatment:YourPHImaybeusedanddisclosedbythosewhoareinvolvedinyourcareforthepurposeofproviding,coordinating,ormanagingyourhealthcaretreatmentandrelatedservices. Thisincludesconsultationwithclinicalsupervisorsorothertreatmentteammembers.WemaydisclosePHItoanyconsultantonlywithyourauthorization.
ForPayment:WemayuseordisclosePHIsothatwecanreceivepaymentforthetreatmentservicesprovidedtoyou.Thiswillonlybedonewithyourauthorization.Examplesofpayment-relatedactivitiesare:makingadeterminationofeligibilityorcoverageforinsurancebenefits,processing claimswithyourinsurancecompany,reviewingservicesprovidedtoyoutodeterminemedical necessity,orundertakingutilizationreviewactivities.Ifitbecomesnecessarytousecollection processesduetolackofpaymentforservices,wewillonlydisclosetheminimumamountofPHI necessaryforpurposesofcollection.
ForHealthCareOperations:Wemayuseordisclose,asneeded,yourPHIinordertosupportourbusinessactivities,including,butnotlimitedto,qualityassessmentactivities,employeereview activities,remindingyouofappointments,toprovideinformationabouttreatmentalternativesorotherhealthrelatedbenefitsandservices,licensing,andconductingorarrangingforotherbusinessactivities.Forexample,wemayshareyourPHIwiththirdpartiesthatperformvariousbusinesses
1 | Page NV PSYCH DOC LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401
Activities for our company(e.g.,billingortypingservices)providedwehaveawrittencontractwiththebusinessthat requiresittosafeguardtheprivacyofyourPHI.Fortrainingorteachingpurposes,PHIwillbedisclosedonlywithyourauthorization.
RequiredbyLaw:Underthelaw,wemustmakedisclosurestoyouuponyourrequest.Inaddition,we mustmakedisclosurestotheSecretaryoftheDepartmentofHealthandHumanServicesforthepurposeofinvestigatingordeterminingourcompliancewiththerequirementsofthePrivacyRule.
FollowingisalistofthecategoriesofusesanddisclosurespermittedbyHIPAAwithoutanauthorization.
Abuseand NeglectJudicialandAdministrativeProceedings
EmergenciesLawEnforcement
NationalSecurityPublicSafety(DutytoWarn)
WithoutAuthorization:ApplicablelawandethicalstandardspermitThe Practicetodiscloseinformation aboutyouwithoutyourauthorizationonlyinalimitednumberofothersituations.Thetypesofusesanddisclosuresthatmaybemadewithoutyourauthorizationarethosethose are:
•Requiredbylaw,suchasthemandatoryreportingofchildabuse, elder abuse, orneglectormandatorygovernmentagencyauditsorinvestigations(suchastheNevadaStateBoardofPsychological Examinersorthehealthdepartment.)
•RequiredbyCourtOrder
•Necessarytopreventorlessenaseriousandimminentthreattothehealthorsafetyofa personorthepublic.Ifinformationisdisclosedtopreventorlessenaseriousthreat,itwill bedisclosedtoapersonorpersonsreasonablyabletopreventorlessenthethreat,includingthetargetofthethreat.
VerbalPermission:Wemayuseordiscloseyourinformationtofamilymembersthataredirectlyinvolvedinyourtreatmentwithyourverbalpermission.
WithAuthorization:Usesanddisclosuresnotspecificallypermittedbyapplicablelawwillbemadeonlywithyourwrittenauthorization,whichmayatanytimeberevoked.
YOURRIGHTSREGARDINGYOURPHI
YouhavethefollowingrightsregardingyourpersonalPHImaintainedbyouroffice.Toexerciseanyoftheserights,pleasesubmityourrequestinwritingtoThe Practice.
•RightofAccesstoInspectandCopy.Youhavetheright,whichmayberestrictedonlyin exceptionalcircumstances,toinspectandcopyPHIthatmaybeusedtomakedecisions aboutyourcare.YourrighttoinspectandcopyPHIwillberestrictedonlyinthosesituationswherethereiscompellingevidencethataccesswouldcauseseriousharmtoyou.Wemaychargeareasonablecostbasedfeeforcopies.
1 | Page NV PSYCH DOC LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401
•RighttoAmend.IfyoufeelthatthePHIwehaveaboutyouisincorrectorincomplete,you mayaskustoamendtheinformation,althoughwe arenotrequiredtoagreetothisamendment.
•RighttoAccountingofDisclosures.YouhavetherighttorequestanaccountingofthedisclosuresthatwemakeofyourPHI.Wemaychargeyouareasonablefeeifyourequestmorethanoneaccountinginany12-monthperiod.
•RighttoRequestRestrictions.Youhavetherighttorequestarestrictionorlimitationon theuseordisclosureofyourPHIfortreatment,payment,orhealthcareoperations.We arenot requiredtoagreetoyourrequest.
•RighttoRequestConfidentialCommunication.Youhavetherighttorequestthatwe communicatewithyouaboutmedicalmattersinacertainwayoratacertainlocation.Pleasemakethisrequestinwriting.
•RighttoaCopyofthisNotice.YouhavetherighttoacopyofthisNotice.
COMPLAINTS
Ifyoubelieveyour provider or any NV PSYCH DOC LLC staff member hasviolatedyourprivacyrights,youhavearighttofileacomplaintinwritingwithDr. SeguraorwiththeSecretaryofHealthandHumanServicesat200IndependenceAvenue,S.W.,Washington,D.C.20201,orbycalling(202)619‐0257.YouarewithinyourlegalrighttofileacomplaintandcanbeassuredNV PSYCH DOC, LLC, will handle it with professionalism and ethical responsibility.TheeffectivedateofthisNoticeis2/1/2015.
1 | Page NV PSYCH DOC LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401
NoticeofPrivacyPractices
ReceiptandAcknowledgmentofNotice
ClientName:
DateofBirth:SocialSecurityNumber:
IherebyacknowledgethatIhavereceivedandhavebeengivenanopportunitytoreadacopyofthePrivacyPracticesforNV PSYCH DOC, LLC. IunderstandthatifIhaveanyquestionsregardingtheNoticeormyprivacyrights,IcancontactDr. Kriston Seguraat 702-308-5114.
SignatureofClient
SignatureofParent,GuardianorPersonal Representative*
______Date
*Ifyouaresigningasapersonalrepresentativeofanindividual,pleasedescribeyourlegalauthoritytoactforthisindividual(e.g.,powerofattorney,healthcaresurrogate,legalguardian).
ClientRefusestoAcknowledgeReceipt:
SignatureofStaffMemberDate
1 | Page NV PSYCH DOC LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401
Cancellation Policy
If you fail to cancel a scheduled appointment, we cannot use this time for another client.You will be billed a fee of $50.00 the first time an appointment is cancelled without 24 hour notice, or if you fail to come to a scheduled session. After the first time, and any time thereafter, you will be billed the full charge of $150 for any missed appointments. Browning Psychological Services is bound by the ethics code to apply policies to all clients; therefore, no exceptions or waivers to this policy will be made unless documentation of an emergency can be provided.A bill will be mailed directly to all clients who do not show up for or cancel an appointment.
Thank you for your consideration regarding this important matter.
Responsible Party Signature (Client’s Parent/Guardian if under 18 or under conservatorship)
Date
1 | Page NV PSYCH DOC LLC, 2110 E. Flamingo Rd., Suite # 317, Las Vegas, NV 89119
Phone: 702.308.5114 Fax: 702.410.8401