Welcome to my practice. This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new 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, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information by the end of our session. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in 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.
Please note: Bryce Gibbs, Ph.D. is an independent, licensed psychologist and is solely responsible for his clinical practice. Other clinicians practicing at 1717 West Avenue are separately licensed, independent practitioners and are professionally and legally responsible for each of their respective practices. Thus, unless otherwise explicitly stated in writing, Bryce Gibbs, Ph.D. and these practitioners are affiliated only through sharing office space at 1717 West Avenue, Austin, Texas.
PSYCHOLOGICAL SERVICES
My practice is a primary “telehealth practice.” Unless an agreement for a singular in-person session has been made in advance, each therapy session will be held virtually. If you feel that your individual needs would best be met with treatment from a clinician conducting fully “in-person” psychotherapy, my staff and I will be happy to find an appropriate referral. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you are experiencing. There are many different methods I may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our 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 many benefits. 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.
Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, I will be able to offer you some first impressions of what our work will include and a treatment plan to follow if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion. If you wish to terminate your therapy, please give notice so that we may work through the termination process.
APPOINTMENTS
Each virtual therapy session is a 55-minute appointment. At the time of your virtual initial intake appointment, we can both discuss if I am the best person to provide the services you need in order to meet your treatment goals. If you decide to continue psychotherapy with me, I will usually schedule one 55-minute virtual therapy session per week at a time we agree on; however, based upon your individual needs, these sessions may be more or less frequent. If you need to cancel an appointment, please notify the office at least 24 hours in advance. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. Please note, I do not accept insurance as a form of payment, though my staff can provide diagnostic codes if you want to pursue out of network reimbursement on your own.
CONTACTING ME
Due to my work schedule, I am often not immediately available by telephone. My staff monitors phone calls and emails within normal business hours, and they will make every effort to return your call within the same business day, or within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform my staff of some times when you will be available. If you are unable to reach me and feel that you cannot wait for me or my staff to return your call, please contact your family physician or the nearest emergency room (ask for the psychiatrist on call). If I will be unavailable for an extended time, I will provide you with the name of a colleague to contact, if necessary. Another direct way of confidential communication with me is at my encrypted email address: drgibbs@psychdocs.net. This email is monitored frequently and strictly confidential.
PATIENT RIGHTS
You have the following rights:
- To be informed of the various steps and activities involved in treatment, and of the cost of services before they are provided.
- To confidentiality under federal and state laws relating to psychological services.
- To humane care, freedom from sexual advances, and freedom from discrimination and exploitation.
- To make a decision about accepting or refusing treatment.
- To contact and consult with legal counsel at the patient’s expense.
- To report complaints to the Texas State Board of Examiners of Psychologists, which can be contacted at 333 Guadalupe, Suite 2-450, Austin, Texas, 78701, (512) 305-7700, www.tsbep.state.tx.us
In addition, HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights (and applicable limitations) are explained more fully in the Notice form, and include the right to:
- Request that I amend your record.
- Request restrictions on what information from your Clinical Record is disclosed to others.
- Request an accounting of most disclosures of protected health information that you have neither consented to nor authorized.
- Determine the location to which protected information disclosures are sent.
- Have any complaints you make about my policies and procedures recorded in your records
- Obtain a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures.
PROFESSIONAL FEES
My fee schedule is as follows:
Psychotherapy:Initial Psychotherapy Evaluation
Individual Psychotherapy Session$400.00 per session (55 minutes)
$350.00 per session (55 minutes)
*Please note- I will sometimes offer a reduced fee based upon unique circumstances such as financial hardship.
IMPORTANT: Please pay careful attention to the fee schedule below if you are pursuing a standard psychological assessment. The full fee of $3800 is expected at the time of the clinical interview. The clinical interview for testing is conducted via telehealth conferencing (55 minutes). At this time, we will discuss the nature of your or your child’s presenting concerns. The psychological assessment (full day of testing 5-6 hours) will then be conducted in person, at our office, with our licensed psychometrician. From here, we will engage in a telehealth conference feedback session (55 minutes), where we will discuss findings of the testing process. After the feedback session, you will shortly receive a comprehensive report, which we can also send to other providers/institutions, should you authorize us to do so. If you are going to cancel the test administration, please call within 24 hours, as an entire day is reserved for the testing process. For a “high stakes testing” psychological assessment, the full fee of $4500 is expected at the time of the clinical interview. The process is much the same as the standard psychological assessment, with the difference being that my staff and I will assist you through the “accommodations application process” for your respective high stakes test (i.e., the GMAT, GRE, LSAT, MCAT, etc).
Standard Psychological Assessment Full Fee: $3800
High Stakes Testing Psychological Assessment Full Fee: $4500
Clinical Interview for Testing
Psychological Assessment
Feedback Session
Telemedicine initial interview (55 minutes)
Full day of testing in office (Estimated 5-6 hours)
Telemedicine interview to discuss results (55 minutes)
At this time, I do not currently take insurance; however, my staff are able to provide you with insurance codes should you decide to file with your insurance on your own.
If I become involved in a legal proceeding, my hourly fee is $500 per hour. This includes discussions with attorneys, document and report preparation (outside of an official testing report), travel time to and from the courthouse, time spent at a courthouse, and time spent testifying. I generally do not conduct forensic evaluations; however, if I agree to a forensic evaluation, I charge a flat rate of $6000 for the complete evaluation (initial interview; day of testing; report preparation; and feedback). My fee of $500 per hour applies to additional time spent on a court case outside of the assessment process.
BILLING AND PAYMENTS
You will be expected to pay for each session at the time it is held unless we agree otherwise. Payment schedules for other professional services will be agreed to when they are requested. Any special arrangement regarding payment must be agreed upon prior to commencing treatment. A $25.00 fee will be charged for returned checks.
If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, I have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require me to disclose otherwise confidential information. I will inform you in writing if I intend to exercise this option, to provide you with a final opportunity to make payment arrangements. In most collection situations, the only information I release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.
LIMITS ON CONFIDENTIALITY
The law protects the privacy of all communications between a patient and a psychologist. In most situations, I can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:
- I may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, I make every effort to avoid revealing the identity of my patient. The other professionals are also legally bound to keep the information confidential. I will always tell you about these consultations prior to engaging in them.
- Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations where I am permitted or required to disclose information without either your consent or Authorization:
- If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your (or your legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
- If your psychologist was appointed by the court to evaluate you, I may be required to disclose confidential information.
- If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.
- If a patient files a complaint or lawsuit against me, I may disclose relevant information regarding that patient in order to defend myself.
- If a patient files a worker’s compensation claim, I must, upon appropriate request, provide records relating to treatment or hospitalization for which compensation is being sought.
There are also some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.
- If I have cause to believe that a child under 18 has been or may be abused or neglected (including physical injury, substantial threat of harm, mental or emotional injury, or any kind of sexual contact or conduct), or that a child is a victim of a sexual offense, or that an elderly or disabled person is in a state of abuse, neglect or exploitation, the law requires that I make a report to the appropriate governmental agency, usually the Department of Protective and Regulatory Services. Once such report is filed, I may be required to provide additional information.
- If I determine that there is a probability that the patient will inflict imminent physical injury on another, or that the patient will inflict imminent physical, mental or emotional harm upon him/herself, I may be required to take protective action by disclosing information to medical or law enforcement personnel or by securing hospitalization of the patient.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is required, formal legal advice may be needed.
MINORS & PARENTS
Patients under 18 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. However, if the treatment is for suicide prevention, chemical addiction or dependency, or sexual, physical or emotional abuse, the law provides that parents may not access their child’s records. For children between 14 and 18, because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is my policy to request an agreement from the patient and his/her parents that the parents consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, 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 my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
PROFESSIONAL RECORDS
You should be aware that, pursuant to HIPAA, I keep Protected Health Information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a diagnosis (if applicable), your medical and social history, your treatment history, any past treatment records that I receive from other providers, your billing records, and any testing reports that have been generated. Except in unusual circumstances that involve danger to yourself and others, you may receive a copy of your Clinical Record if you request it in writing. Pursuant to Texas law, we have 15 days to respond to a records request. You should be aware that also pursuant to Texas law, psychological test data are not part of a patient’s record. Because these are professional records, they can be misinterpreted and/or upsetting to untrained 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. In most circumstances, I am allowed to charge a copying fee of $0.25 per page (and for certain other expenses). The exceptions to this policy are contained in the attached Notice Form. If I refuse your request for access to your Clinical Record, you have a right of review, which I will discuss with you upon your request.
In addition, I also keep a set of Psychotherapy Notes. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal.
Please note: when I engage in couple’s therapy, I keep one file for the couple. Within this file, information about you and your partner may be comingled. Because a couple’s record contains protected health information for two individuals, joint consent is required for the release of the Clinical Record. For instance, if you submit a written request for a copy of your couple’s record, the other party will have to provide written consent for the Clinical Record to be released (or vice versa).
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA NOTICE FORM DESCRIBED ABOVE. YOUR SIGNATURE ALSO INDICATES THAT YOU HAVE BEEN INFORMED OF AND UNDERSTAND THE LIMITATIONS ON PATIENT CONFIDENTIALITY.