HIPAA USES AND DISCLOSUREPOLICY

1.Purpose: To provide direction to staff on how to use and disclose protected health information consistent with Clear Brook Counseling Professionals, LLC’s commitment to quality patient care and our patients’ confidentiality. This policy is intended to comply with the requirements of the HIPAA Privacy Rule and Iowalaw.

2.Internal Uses: Clear Brook Counseling Professionals, LLC will use patients’ protected health information for treatment, payment and health care operations. Information will be provided to staff on a medical need to know basis for each of these functions. With regard to payment and health care operations, Clear Brook Counseling Professionals, LLC will make a determination as to what information is the minimum necessary information for each employee to receive for internal uses consistent with Clear Brook Counseling Professionals, LLC policy concerning “minimum necessaryinformation.”

3.ExternalDisclosures:

3.1Disclosures to patients or personal representatives: Clear Brook Counseling Professionals, LLC may disclose protected health information to the patient without authorization or consent. In the event that the patient lacks the capacity to agree (either because the patient is a minor or has an incapacitating mental or physical impairment), we may disclose protected health information to the patient’s personal representative consistent with Clear Brook Counseling Professionals, LLC’ policy and procedures.

Notwithstanding the foregoing, Clear Brook Counseling Professionals, LLC may elect not to treat an individual as the personal representative of the patient if Clear Brook Counseling Professionals,LLC:

  • Reasonably believes that the patient has been or may be subject to domestic violence, abuse, or neglect by that person;or
  • Reasonably believes that treating that person as the personal representative could endanger the patient or another individual;or
  • In the exercise of professional judgment, decides that it is not in the best interest of the patient to treat that person as the personalrepresentative.
  1. Disclosures pursuant to Notice: Clear Brook Counseling Professionals, LLC may disclose protected health information without written authorization or consent for treatment, payment, and health care operations (i.e., administrative and operational functions including quality assurance and credentialing), if a patient has been provided Clear Brook Counseling Professionals, LLC Notice of Privacy Practices and signed the acknowledgment located at the end of the notice, or you have documented that you have made a good faith effort to obtain the acknowledgment. You may also disclose protected health information for other purposes as listed on the Notice of Privacy Practices. Notwithstanding the foregoing, if the protected health information includes HIV/AIDS related information, mental health treatment information or substance abuse treatment information, we will obtain a written authorization that specificallyauthorizesthe release of such information (see Authorization to Release Information form). In addition, if the protected health information includes psychotherapy notes, then you must similarly obtain an authorization (See 3.7below.)
  2. Disclosures to individuals involved in the patient’s care: Because Clear Brook Counseling Professionals, LLC’s Notice of Privacy Practices so informs the patient, and if the patient has not objected to such disclosure, Clear Brook Counseling Professionals, LLC may disclose protected health information to a family member, other relative, or a close personal friend of the patient, or any other person identified by the individual as being involved in the patient’s care, if the information is directly relevant to that person’s involvement with the individual’s care, under any of the followingcircumstances:

a)If the patientagrees.

b)If the patient fails toobject.

c)Whether the patient is present or not, if the Clear Brook Counseling Professionals, LLC reasonably infers from the circumstances, based on the exercise of professional judgment, which the individual does not object to the disclosure.

d)If the patient cannot agree or object because of incapacity (either temporary or permanent), for example because of a mental or physical condition, and Clear Brook Counseling Professionals, LLC, exercising professional judgment and based on common practice, determines that the disclosure is in the best interest of thepatient.

e)If the patient cannot agree or object because of an emergency, and Clear Brook Counseling Professionals, LLC, exercising professional judgment and based on common practice, determines that the disclosure is in the best interest of thepatient.

3.4Disclosure to individuals involved in payment for a patient's care: If the Notice of Privacy Practices so informs the patient, and the patient has not objected to such disclosure, Clear Brook Counseling Professionals, LLC may disclose such information to an individual involved in payment related to the individual’s health care if the conditions of 3.3 aremet.

3.5Disclosures for notification purposes: If the Notice of Privacy Practices so informs the patient, and the patient has not objected to such disclosure, or if the Clear Brook Counseling Professionals, LLC reasonably infers from the circumstances, based on the exercise of professional judgment, that the patient would not object, Clear Brook Counseling Professionals, LLC may disclose protected health information to notify or assist in the notification to a family member, a personal representative of the individual or another person responsible for the care of the individual of the individual’s location, general condition, ordeath.

3.6Providing x-rays, prescriptions, and other medical supplies, or other protected health information to third parties: Clear Brook Counseling Professionals, LLC may use professional judgment and common practice to determine whether it is in the best interests of a patient to allow a person to act on behalf of the patient to pick up x-rays, prescriptions, other medical supplies, or other protected healthinformation.

3.7Disclosures pursuant to authorization: Clear Brook Counseling Professionals, LLC may disclose protected health information to third parties such as employers with an authorization. Further, if the protected health information includes HIV/AIDS related information, mental health treatment information or substance abuse treatment information, you must obtain an authorization that specifically authorizes the release of such information. In addition, if the protected health information includes separate psychotherapy process notes, then you must similarly obtain a specificauthorization.

3.8Disclosures to Business Associates: Clear Brook Counseling Professionals, LLC may disclose protected health information to consultants, vendors, or other independent contractors who have a business associate relationship with provider, who have signed a business associate agreement or addendum. “Business Associates” are consultants who render advice or services to or on behalf of Clear Brook Counseling Professionals, LLC. The "minimum necessary" standard willapply.

3.9Disclosures to a law enforcement official: Clear Brook Counseling Professionals, LLC may disclose protected health information for the purpose of identifying, locating a suspect, fugitive, material witness or missing person (excluding Mental Health and Substance Abuse records, which are protected by Iowa law.) A law enforcement agency is prohibited from using the PHI for purposes other than the reason it was requested and requires the agency to return the information to Clear Brook Counseling Professionals, LLC or destroy the information at the end of the litigation. This information is limitedto:

  • Name andaddress
  • Date and place ofbirth
  • Social securitynumber
  • Blood type and Rhfactor
  • Type ofinjury
  • Date and time oftreatment
  • Date and time of death, if applicable,and
  • A description of distinguishing physical characteristics, including height, weight, gender, race, hair and eye color, presence or absence of facial hair (beard or moustache), scars andtattoos

Clear Brook Counseling Professionals, LLC may also make disclosures about a patient who has died to a law enforcement official if it suspects that the death may have resulted from criminalactivity.

4.Prohibition against selling PHI: Clear Brook Counseling Professionals, LLC will not directly or indirectly receive any payment or other remuneration in exchange for any PHI unless we receive a valid authorization that includes a specification of whether the PHI can be further exchanged for remuneration by the entity receiving PHI. The prohibition against selling PHI will not apply if the purpose of the transaction isfor:

a)providing a patient with a copy of his/her medicalrecord.

b)public healthactivities.

c)research, but only if the price charged reflects the costs of preparation and transmittal of the data for suchpurpose.

d)treatment of the individual, subjected to any regulation that the Secretary may promulgate to prevent PHI from inappropriate access, use, ordisclosure.

e)health care operations associated with the sale, transfer, merger, or consolidation of all or part of Clear Brook Counseling Professionals,LLC.

f)payment provided by Clear Brook Counseling Professionals, LLC to a Business Associate pursuant to a legitimate Business Associate services contract orarrangement.

g)any other purpose approved by the Secretary of Health and HumanServices.

5.Disclosures for marketing purposes: Clear Brook Counseling Professionals, LLC may use or disclose limited PHI for purposes of marketing if the patient signs an authorization specifically authorizing the use or disclosure. If Clear Brook Counseling Professionals, LLC receives remuneration for such marketing from a third party, the authorization will disclose this fact. A patient may opt out of any marketing communications, effective upon notice to Clear Brook Counseling Professionals,LLC

6.Fundraising: Clear Brook Counseling Professionals, LLC may use limited PHI for purposes of fundraising, including name of resident, dates of service, and the nature of the outcome of the services. The patient must be given the opportunity to opt out of suchcommunications.

SignatureofClient

Date

OWI –321J

CONSENT TO RELEASE ALCOHOL AND DRUG ABUSEINFORMATION

I,authorize:

(Client Name – Please Print orType)

Clear Brook Counseling Professionals,LLC

(NameofOrganization,SubstanceAbuseTreatmentProgram,orPersontoReleasetheInformation)

614 Billy Sunday Road, Suite100

(Address)

Ames IA50010

(City)(State)(ZIP)

to release the information specified belowto:

IOWA DEPARTMENT OF TRANSPORTATION MOTOR VEHICLEDIVISION

Information tobereleased:YESNO

Screening/Evaluation Recommendation

TreatmentCompletion

The only purpose(s) for the disclosure of the above informationis:

Facilitate compliance regarding OWI (321J) and DOTrequirements

Other (specify)

I voluntarily allow the release of the above named information. No threat or other coercive measures have induced me to sign this consent form. I understand this information will not be forwarded to anyone else by the recipient without my written consent. I have been informed concerning current federal confidentiality regulations regarding alcohol and drug abuse patientrecords.

This authorization is effective for 6 months after the date it is signed; or,until______.

(specify date, event, or condition upon which this consentexpires)


SignatureofClientDate

CONFIDENTIALITY OF ALCOHOL AND DRUG ABUSE PATIENTRECORDS

The confidentiality of alcohol and drug abuse patient records maintained by Clear Brook Counseling Professionals, LLC is protected by federal law and regulations. Generally, Clear Brook Counseling Professionals, LLC may not inform anyone outside of the organization that a patient has receivedsubstance abuse services from Clear Brook Counseling Professionals, LLC, or disclose any information identifying a person as an alcohol or drug abuser,Unless:

  1. The patient consents inwriting;
  2. The disclosure is allowed by a court order;or
  3. The disclosure is made to medical personnel in a medical emergency or to qualified personnelfor research, audit, or programevaluation.

Violation of the federal law and regulations by a program is a crime. Suspected violations may be reportedto appropriate authorities in accordance with federalregulations.

Federal law and regulations do not protect any information about a crime committed by a patient eitherat

Clear Brook Counseling Professionals, LLC or against any person who works for Clear Brook Counseling Professionals, LLC or about any threat to commit such acrime.

Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state or localauthorities.

See42U.S.C.§290dd-3and42U.S.C.§290ee-3forfederallawsand42C.F.R.Part2forfederalregulations.

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AdditionalInformation

  • The fee for the substance abuse screening is $125. The fee must be paid before the service isprovided.
  • We are committed to providing you with a clinically sound substance abuse screening, and to providing you a service that meets your needs. We strive to resolve issues and concerns directly and informally as thisapproach is often most effective. In the event that a concern is not resolvable this way, you are encouraged to request a Patient Complaint Form from the clinician you have seen or from any of the office staff. Submission of this form will allow any concern to be pursued in a more formalway.

I understand this information, and I have been offered a copy for myrecords.

SignatureofClientDate

INFORMED CONSENT FORSERVICES

PSYCHOLOGIST-CLIENT SERVICE AGREEMENT

Welcome to Clear Brook Counseling Professionals. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

PSYCHOLOGICAL SERVICES

Therapy is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you. These rights and responsibilities are described in the following sections.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

The first 2-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, we will be able to offer you some initial impressions of what our work might include. At that point, we will discuss your treatment goals and create an initial treatment plan. You should evaluate this information and make your own assessment about whether you feel comfortable working with your provider. If you have questions about the procedures, we should discuss them whenever they arise. If your doubts persist, your provider will be happy to help you set up a meeting with another mental health professional.

APPOINTMENTS

Appointments will ordinarily be 40-50 minutes in duration. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, I ask that you provide us with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24 hour notice, or if you are 10 or more minutes tardy for your appointment without calling, our policy is to collect $75.00 [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If it is possible, we will try to find another time to reschedule the appointment on the same day, which we will then waive the fee. In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

PROFESSIONAL FEES

The standard fee for the initial intake is $200.00 and each subsequent session is $130.00 if you are paying on a cash basis. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check, cash credit or debit card. Any checks returned to the office are subject to an additional fee of up to $30.00 to cover the bank fee. If you refuse to pay your debt, we reserve the right to use an attorney or collection agency to secure payment.

In addition to appointments, it is our practice to charge this amount on a prorated basis (We will break down the hourly cost) for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of us. If you anticipate becoming involved in a court case, we recommend that we discuss this fully before you waive your right to confidentiality. If your case requires our participation, you will be expected to pay for the professional time required even if another party compels us to testify.

INSURANCE

In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. With your permission, my billing service will assist you to the extent possible in filing claims and ascertaining information about your coverage, but you are responsible for knowing your coverage and for letting us know if/when your coverage changes.