Therapy Contract

Patient Agreement with Policies and Procedures

Welcome to ABC! The following information is provided to assist you in understanding our policies and procedures. We strive to provide you care which is both comfortable and of the highest quality. Please do not hesitate to ask questions of your therapist or the administrative staff about these matters.

Appointments:

Since patients are seen by appointment only (unless an emergency situation dictates otherwise), the appointment time given is 50 minutes that has been reserved for you. Please give at least twenty-four (24) hours notice if you
must cancel your reserved time. Sometimes illness and emergencies happen
which prevent you from keeping your appointment and we do not charge for
these infrequent occurrences.

In the absence of such circumstances, you will be charged a$ 25.00 no-show fee for missed appointments not cancelled twenty-four hours in advance of the time. Please understand that insurance companies cannot be billed for missed appointments and you are fully responsible for any charge due to missed appointments.

Emergencies and Telephone Calls:

While you will be seen at a reserved time which fits your schedule demands, there may arise occasions when you need to talk to your therapist between appointments. Should this occur, you should call the office during normal office hours and leave a message for your therapist to return your call.

If your call is an emergency, you should declare your call to be an emergency, And your call will be handled promptly.

You may leave a message at our office 24 hours a day. Someone will retrieve
after-hours messages at the beginning of the next work day and your call will be returned. If you are in an emergency situation after our office is closed , you should go to the nearest Emergency Room, call 911 or the Crisis Hot line at 855-274-7471.

Fees and Payments:

Fees are contingent on the type of service provided. The initial diagnostic session is $150.00. All payments, including co-payments, deductibles, and co-insurance amounts are due at the time services are rendered unless prior arrangements have been made with the therapist or with the office manager.

Insurance Usage and Issues of Confidentiality and Privileged Communications:

Many patients elect to file third party insurance coverage, including Medicare, for services rendered. We will file insurance claims for you, provided you authorize us to do so and provide us with the necessary information for filing such claims. It is our responsibility is to inform you about the compromising of your confidentiality and privacy when complying with the requirements of insurance companies. The compromising of your confidentiality is standard in today’s marketplace whenever one chooses to use third party insurance coverage for services rendered. Fortunately the newly enacted HIPAA regulations do provide you an increased degree of privacy and confidentiality regarding your protected health information. Payors of care can no longer make full release of your mental health record a condition for payment of your claims.

Instead, release of your mental health records is limited only to your designated mental health record set and not psychotherapy notes made during sessions. What you talk about in your established relationship with your therapist is protected by privileged communication laws of the State of Tennessee and confidentiality principles, with the exception of certain specific actions (i.e., clear and imminent danger to self or others, suspected child abuse, worker’s compensation related cases, if your mental health becomes an issue in a lawsuit, whatever information is shared in utilization review reports for authorization of care, compliance with chart audits by your insurance carrier). With these exceptions, unless you specifically sign a release of information authorizing release of protected health information, all communications are kept private, confidential, and privileged.

We strive to maintain the sacredness and privacy of your confidential communications with us.