Office Policies, Agreement & Important Information

I know you may have questions about my policies, privacy practices, fees, and how I will work with your insurance company. I hope this information answers many of your questions. I will gladly answer your questions and look forward to working with you.

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 with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

The HIPAA requires that I provide you with a Notice of Privacy Practices. This notice, which appears here, explains the privacy in greater detail. The law requires that I ask for your signature acknowledging that I have provided you with this information.

Risks & Benefits of Psychotherapy

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 often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress.

Fees & Co-Payments

Unless other arrangements have been made, co-payments are expected at each visit. Unless you have authorized me to make arrangements with your insurance company, I charge my customary and usual fees. As with all professional services, you are responsible for the fee, unless other arrangements have been made. Your insurance may require a co-payment with each visit. I accept MasterCard, Visa, and cash. My fee structure is subject to change. Please make checks payable to ChangePoint.

Cancellation & Missed Appointments

Scheduled times are held exclusively for you. I require a 24 hour advance notice of a cancellation. Cancellation messages may be left with office staff or voice mail. If it is necessary to cancel an appointment, please give me as much notice as possible. Unless it is weather related or an emergency, I request at least 24 hours’ notice. I charge $75.00 for missed appointments or those cancelled without 24-hour notice. This charge cannot be billed to your health insurer.

Insurance Coverage, Claims, & Privacy

It is important that you review the section of your health insurance coverage information that describes mental health benefits. By signing this agreement, you agree that I can provide requested information to your health insurer. I will fill out standard claim forms and provide you with whatever assistance I can to help you receive your benefits. If your insurance carrier denies payment, you remain responsible for the full payment of the fee.

I can submit claims to your primary insurance carrier on your behalf; but you should be aware this requires that I disclose information to them, including a diagnosis and dates of your visits. Some insurance plans require us to provide additional information. All insurance companies claim to keep such information confidential, but once it is in their hands, I have no control over what they do with it. In some cases they may share the information with a national medical information data bank.

If you prefer that I do not submit heath related information to your health insurer, you can choose to self-pay for services privately. No claim will be submitted.

Bills & Statements

I send out statements if an amount is due. Payment in full is due within 30 days. I charge a $5 monthly rebilling fee on overdue accounts with unpaid balances over 30 days old. If your account is more than 90 days in arrears and suitable arrangements for payment have not been agreed to, I have the option of using a collection agency or small claims court. If legal action is necessary, the costs of bringing that proceeding will be included in the claim.

Phone Calls & Emergencies

My voice mail is checked regularly. Please leave routine messages including appointment cancellations on my voice mail if you cannot reach me at the office directly. I will return your call as soon as I can. I do not charge for occasional non-emergency phone calls, but I do encourage you to discuss your concerns during scheduled times. If your call is an emergency, please be sure to let me know in your message. If there is an emergency and you are unable to reach one of our professionals, you should go to the nearest hospital emergency department.

Confidentiality & Privacy Safeguards

I strive to protect your privacy. No information is released outside of the practice without your permission. Connecticut law and professional ethics protect the privacy of all communications between a psychologist and a patient. In most situations, I only release information about your treatment to others if you sign a written Authorization for Release of Information Form. There are some situations in which I am legally obligated to take actions including revealing information about a patient that I believe is necessary to protect others from harm. These situations are unusual in this practice.

• State law requires us to report suspected abuse and neglect of children. If I suspect abuse or neglect, we are obligated to report it.
• If I believe or suspect an elderly, disabled, or incompetent individual has been abused, I may have to report this to the appropriate authority.
• If I believe there is an emergency situation when harm is possible to you or others, I will do what is required to protect you or another person. I may need to notify someone of the emergency.
• If I receive a subpoena from court, I will try to inform you about it so you can take legal action to stop the subpoena if you wish. I will assert your confidentiality privilege on your behalf, unless you waive it, but will have to release your records or testify if ordered to do so by a court.

Professional Records

The standards of clinical psychology and health care laws require I keep Protected Health Information (PHI) about you in your Clinical Record and, in some cases, a set of Psychotherapy Notes. Except in unusual circumstances that involve danger to yourself and others or where information has been confidentially supplied to us by others, you may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted or be upsetting to some readers. For this reason, I recommend that you initially review them in my presence or have them forwarded to another mental health professional so you can discuss the contents. We are sometimes willing to conduct a review meeting without charge. In most situations, we charge a copying fee of $.50 per page with a minimum charge of $5.00. If we refuse your request for access to your records, you have a right of review, which your psychologist or Dr. Geysen will discuss with you upon request.

I typically do keep Psychotherapy Notes as described in the HIPAA. In the cases in which I do, you should be aware that the notes might contain particularly sensitive information that you may have revealed. These Psychotherapy Notes are not required to be included in the Clinical Record. These Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies, without your written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide it.

Minors & Parents

Patients under 16 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records unless I decide that such access is likely to injure the child. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, Dr. Geysen will provide them only with general information about attendance and the progress of the child’s treatment. Any other communication will require the child’s consent, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of the psychologist’s concern. Before giving parents any information, Dr. Geysen will usually discuss the matter with the child, if possible, and to handle, as best as possible, any objections the child may have.

Supervision of Children

A parent or guardian must supervise young children. Young children may not be left alone in the waiting area. Please do not allow children to roam the halls. It can be disruptive to persons who are working.