Terms of Billing and Telehealth Consent

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Welcome to Northwest Counseling! We are so happy you are here. We understand life does not
always go the way you planned for it and we believe each us has our own story. We want to know
your story and help you learn how to reach your highest potential. Each individual will be treated
with respect and dignity regardless of their race, creed, sex, sexuality, national origin and/or
handicap. We will provide competent, quality and ethical therapy as we work together in helping
you create the story you have been searching for.
To view HIPPA policies please see our website at www.sartellcounseling.com or ask your therapist
for a copy
Emergencies: If you, or someone you know, is experiencing a mental health crisis during business hours
please call us at 320-316-0288. If your therapist is available you will be directed to that therapist. If not, you
will be asked if you would like to speak to an available therapist. If it is after office hours you may call the St.
Cloud Hospital at 320-251-2700 or the Mental Health Crisis Hotline at 320-253-5555 or 1-800-635-8008. If it
is an emergency situation that requires immediate action, call 911 or go to the nearest emergency room.
Assessment and Treatment: At your initial appointment, your therapist will complete a diagnostic
assessment to make recommendations for treatment and formulate diagnosis. After the assessment, a
treatment plan will be created that will include: diagnosis, length of treatment, goals and strategies. You will
be a part of the treatment planning process and asked to sign this document.
There are many different approaches used in therapy. It is your right to choose the approach with which
you are the most comfortable. All of our therapists strive to deliver care in the most efficient, least
expensive and least restrictive manner. You always have the right to request another therapist or an
alternative form of therapy. Your therapist also has the right to decide if it is an appropriate fit and within
his/her competency to treat. If it is determined that counseling with your therapist will not continue, your
therapist will assist you in a referral.
Therapy Risks/Benefits: Therapy often leads to better relationships, solutions to specific problems and
significant reduction in feelings of distress. Since each individual is unique, there can be no guarantees.
The therapy contract is about change. As in any change process an individual may experience
discomfort/pain. Emotional pain may also intensify because of the subject matter discussed. Individuals
may feel worse before they feel better. Also, when one person changes it may cause discomfort for others
around him or her which could cause a strain in one’s relationships. We are skilled in involving family
members to minimize these negative effects if and when they occur.
Other specific types of therapies may have other known risks. For example, certain therapies which assist
you in remembering the past may have a potential side effect of creating memories which may not be
accurate or literally true. Discuss any concerns with your therapist.
Social Media:
Email: We have HIPPA approved email and can accept your completed initial paperwork through our email.
However, we will not provide therapy through email accounts and any responses we send are not secured
through email. Please save the information you would like to talk to your therapist for your sessions. We
cannot guarantee responses from emails, please use our emergency plan listed above, in the event of a
Friending: We do not accept friend or contact requests from current or former clients on any social
networking site (Facebook, LinkedIn, etc.) due to confidentiality.
Texting: If you need to cancel your session, you may call or text that information. However, again therapy
will not be given via text messages. You may sign up for phone or text appointment reminders.
Northwest Counseling has a Facebook and Pinterest page with helpful tips and resources listed on it. You
are welcome to follow and/or like posts, at your own discretion. These pages are public, therefore
confidentiality of you following or liking cannot be given to these social networks.
Limits of Confidentiality
As required by law, Northwest Counseling has a formal business associate contract with individuals that
access use of our building for services. This includes maintenance, cleaning and management staff at
Northwest Professional Building and billing services. These individuals maintain the confidentiality of this
data except as specifically allowed in the contract or otherwise required by law. Therapists have a common
billing system, collection agency, record storage facility and cleaning service.
There are a few exceptions to this. We are MANDATED REPORTERS, and by law, we must make a report
if we hear that a child has been or is currently being abused or neglected. We must also break
confidentiality if we believe that you are in imminent danger of harming yourself or another person. In
addition, we are mandated reporters when required by a judge of the court.
At times it is helpful to consult with other providers. Those providers are also legally bound to keep the
information confidential. When other professionals are consulted, every effort is made to not reveal the
identity of the client being discussed. All consultations about your care will be noted in your Clinical Record.
You have a right to request restrictions on the use and disclosure of your protected health information (PHI)
for treatment, payment and health care operations or to family members. We will accommodate reasonable
requests. Once we have agreed to a restriction, we may not violate the restriction, however, PHI may be
provided to another health care provider in an emergency treatment situation.
Payment: We accept cash, check and all major credit cards as forms of payment. Co-pays are due at the
time of service. If you are a private cash pay client, your payment is due in full on the day of the session.
Past Due Accounts: If you have a past due account of $300 or greater, your sessions will be terminated
until payment is received. A past due account is anything over sixty days that has not been paid. If you
need to set up a payment plan, please contact your therapist directly.
Cancellation Policy: If you are unable to attend a session, please make sure you cancel at least 24 hours
beforehand. Otherwise, you will be charged $75 for a no show/late cancel fee. If you are ill, please call the
morning of your appointment to avoid being charged.
Co-Parenting: If you share legal custody of your minor, attending therapy, both parents have to consent
and be informed the child is attending therapy. In addition, health information can be shared to both
parents, unless there is written legal documentation that states one parent does not share legal custody.
Any Other Questions: Please contact us for any additional questions you may have. We look forward to
hearing from you!

TERMS OF BILLING/CONSENT *PATIENT COPY* •Clients are responsible for knowing their insurance benefits and plan requirements. Therefore, if your insurance company does not pay you are responsible for all charges incurred. •The fee for an assessment for an episode of care is $175*. Ongoing therapy is $125* per session (45 minutes). Group therapy cost depends on the group and time commitment. ($25 provider discount when choosing fee for service and paid the day of appointment.) •There is a $75 charge for non-emergency no-shows and/or cancellations made less than 24 hours in advance (unless there are rules that prohibit us from doing this). These cannot be submitted to your insurance company. This must be paid prior to your next scheduled session. If there are repeated cancellations or no-shows the therapist may choose to discontinue care and provide referrals. Therapists can choose to not charge based on reason for the cancellation. •If you become involved in legal proceedings that require your therapist’s participation, you will be expected to pay for all of his/her professional time, including transportation costs, even if he/she is called to testify by another party (fee for preparation and attendance at any legal proceeding is $200 per hour). A retainer sum of $500 shall be placed in the Northwest Account. Services performed by this office will be billed in accordance with this agreement. Because each case is unique, we cannot estimate the amount of time we spend on your case. Therefore, we cannot predict the complete cost you will be required to pay. •If you share legal custody of your minor, attending therapy, both parents have to consent and be informed the child is attending therapy. In addition, health information can be shared to both parents, unless there is written legal documentation that states one parent does not share legal custody. Payment is the responsibility of the legal guardians based on their legal documentation and this office will bill the guarantor, as stated by the parent. It is then the parents responsibilities to coordinate payment to this office. •I will pay my co-payment of each visit and/or the total amount due. •I will notify you immediately of any change in insurance company. Without such notification, any refusal on the part of my insurance carrier to pay for services because of needed preauthorization will be my responsibility. •I consent to release of protected health information to my insurance company or EAP group for the processing of claims, care coordination and treatment determination needed to respond to the inquiry. I understand Northwest Counseling will give only the minimal necessary information needed to respond to the inquiry. •If I am covered or believe I am covered by Medical Assistance (MA), I authorize this office to contact the county or counties as it relates to my MA number and coverage. I also authorize release of protected health information to MA for billing and prior authorization purposes. •If my account becomes past due (60 days) and I have not arranged for or made regular payments, I understand Northwest Counseling may turn my account over to a collection agency and/or small claims court to obtain payment. My failure to make payments or arrange payments to settle my account is tacit authorization for Northwest Counseling to release the minimal protected health information necessary to the collection agency and/or small claims court. I hereby assign all medical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance and other health plans to Northwest Counseling. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as an original. In signing this, I am consenting to: 1) terms of billing 2) release of health information as needed for collection purposes 3) medical benefit assignment 4) Understanding of HIPPA, limits of confidentiality and Client Bill of Rights

Telehealth Consent I ____________________________________________, consent to engaging in telehealth with a Northwest Counseling’s therapist as a part of the therapy process and my treatment goals. I understand that telehealth psychotherapy may include mental health evaluation, assessment, treatment planning, and therapy. Telehealth will occur primarily through interactive audio, video, telephone and/or other audio/video communications. I understand I have the following rights with respect to telehealth: 1) I have the right to withhold or remove consent at any time without effecting my right to future care or treatment. 2) The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information released by me during my sessions is confidential. There are both mandatory and permissive exceptions to confidentiality including but not limited to reporting child and vulnerable adult abuse, expressed imminent harm to oneself or others, or as a part of legal proceedings where information is requested by a court of law. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent. 3) I understand that there are risks unique and specific to telehealth, including but not limited to, the possibility that our therapy sessions could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. 4) Signing this form shows an awareness of these issues and a decision by this client to use these systems for telehealth services. I will not hold Northwest Counseling or therapist liable for gathering or use of client information by these service providers. 5) By signing this document, I agree that certain situations including emergencies and crises are inappropriate for audio/video/computer-based psychotherapy services. In addition, I understand that telehealth treatment is different from in-person therapy and that my therapist will consider these differences in their recommendation. 6) I understand I have the right to access my personal information and copies of case notes. I have read and understand the information provided above. I have discussed these points with my therapist, and all of my questions regarding the above matters have been answered to my approval. 7) I understand that I will need to be in a safe and secure place in order to conduct the session. If the therapist does not feel that I am in a confidential setting, the therapist has the right to discontinue the session.

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