Office Policy | Carolynn Brusseau
Carolynn Brusseau, MA, LPCAccess Counseling Services, Inc.175 Olde Half Day Road, Suite 140-9, Lincolnshire IL 6006919 N. County Street, Waukegan IL email@example.com | 312-600-5367jdanielsphd.com
OFFICE POLICY STATEMENT/AGREEMENT
Welcome to the Access Counseling Services, Inc., at which your therapist Carolynn Brusseau, MA, LPC is employed. This document (the Agreement) contains important information about my professional services and business policies. You will also receive 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. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. If you want to retain a copy of the HIPAA form, please let me know. It is also available on my website. The law requires that I obtain your signature acknowledging that you have been provided with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. Please discuss any questions you have about the procedures with your treatment provider, immediately. When you sign this document, it will also represent an agreement between you and I. You may revoke this Agreement in writing at any time. That revocation will be binding on Carolynn Brusseau, MA, LPC, unless action has been taken with reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
HOW OFTEN CAN I EXPECT TO HAVE AN APPOINTMENT?
Clients normally choose to come once or twice a week, depending on the nature of the issues. In the later phases of treatment, appointments are sometimes scheduled less frequently. Sessions are 45 to 60 minutes long. Occasionally longer sessions may be scheduled. Every effort will be made to schedule sessions at times that are convenient for you.
HOW DO I CONTACT YOU IF NEEDED?
Although the telephone is not a good substitute for talking face-to-face (including telehealth), there may be times when calling/texting or emailing makes good sense. Clients occasionally need to communicate with me between sessions. You will know intuitively if that is the case, and a brief telephone call or email is then welcome. Longer telephone call, texts and emails will incur a charge. Please note that it is likely you will receive a response to communications during my work hours, and only if a response is required. In the event of an emergency, please dial 911, or go to the nearest emergency room.
WHAT HAPPENS IF AN APPOINTMENT IS FORGOTTEN?
Coming regularly and on time is an indication of your commitment to the therapeutic process. Once an appointment is made, that time is set aside for your use. Any cancellation for your appointment must be made 24 hours before your appointment. Cancellations can then be given to clients who need an appointment. Except in the case of an emergency, you will be charged the full $190.00 for any missed or late cancellation. You should note that most insurance companies do not cover missed appointment or late cancellation charges.
WHEN IS IT TIME TO END TREATMENT?
I believe that how long you remain in counseling is a matter best left in your hands. It is important that you feel comfortable in raising the topic at any time.
WHAT ARE MY FINANCIAL RESPONSIBILITIES?
Prior to your first appointment, you will receive a phone call or email with instructions on how to register in our system. At that time you will also be asked to email or text a picture of your insurance card, front and back. We will verify eligibility, but it is your responsibility to be aware of your deductibles and copays. Payment of co-pays, deductibles or out of pocket fees be paid at the time of service. The preferred form of payment is our office charging your card on file. If you prefer to pay by check or Venmo, you may do so. However, we will still require a credit card on file.
At times fees for services other than therapy sessions may be incurred. These may include; printing materials, reports, letters, consultations, travel time for “out of office” services, telephone calls, texts and emails. You will be billed for all the time spent with you or on your behalf.
If your financial situation changes regarding payments, including changes to your insurance, please discuss this with me so we can explore the options open to you.
Payments are due at the time of service. Access Counseling Services, Inc. will automatically electronically bill your insurance and/or collect payment from you after every session. If for some reason you incur a balance, a statement will be mailed to you and payment will be expected within 14 days in order to avoid a $10 late fee. Subsequent notices will also incur a $10 late fee. If no payment arrangement has been made after 45 days your bill will be sent to a collection company and you will be responsible for any additional legal and collection agency fees for the collection of the account.
STATEMENT CONCERNING PAYMENT AND HEALTH INSURANCE BENEFITS
In the event my insurance is billed for services rendered, I hereby authorize payment of Health insurance benefits directly to Access Counseling Services, Inc./ Jennifer Daniels, PhD, LCPC. I authorize the release of any medical information necessary to process these claims, including but not limited to written and/or verbal correspondence with insurance company/managed care. I understand that I am financially responsible or any amount not covered under this authorization.
A FINAL WORD. The counseling relationship is a very personal and individualized partnership. I want to know what you find helpful and what, if anything, may be getting in the way. Periodically we will discuss your progress. Clients often know intuitively the kind of help they want. I want you to feel free to share with me what I can do to help.
PLEASE ASK BEFORE SIGNING BELOW IF YOU HAVE ANY QUESTIONS ABOUT PSYCHOTHERAPY OR THE OFFICE POLICIES. YOUR SIGNATURE INDICATES THAT YOU HAVE READ MY OFFICE POLICIES AND AGREE TO ENTER THERAPY UNDER THESE CONDITIONS. FURTHER, IT INDICATES YOUR UNDERSTANDING THAT I MAY TERMINATE YOUR THERAPY IF YOU DO NOT COMPLY WITH THE POLICIES OR IF I FEEL YOU ARE NOT BENEFITING FROM TREATMENT.
RETURN A COPY FOR YOUR OWN INFORMATION.
I HAVE READ THIS POLICY AND AGREE TO ABIDE BY IT.
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Office Policy | Carolynn Brusseau
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