Expand the Policies Below to Read More
Dual Relationship/Social Media Policy
It is against my professional code of ethics to engage in a dual relationship with clients. This means that I cannot become your friend or engage in a romantic relationship with you. In order to maintain healthy and clear boundaries, I will not acknowledge our therapeutic relationship if I happen to see you in public. If you say “hello” to me, I will smile and nod. I will not accept any requests for friendship on any personal social media platforms. You may follow my business social media accounts and pages if you so choose.
Professional Fees, Billing & Payments Policy
You are responsible for 100% of the costs of services. The rate for a 50 minute session is $100 and is due at the time of service. The initial appointment is $150. You may choose to submit your receipt for services to your insurance for out-of-network benefits but I do not deal directly with your insurance. I am happy to answer any questions you have about using your out-of-network benefits. If you request services for court-related matters, my rate is $200/hour. If you need assistance outside of the office which requires telephone or email contact that exceeds 5 minutes in a 24 hour period, you will be billed my pro-rated session fee of $100/50 minutes for the time spent responding to your concern/situation/issue.
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. [If such legal action is necessary, its costs will be included in the claim.] 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.
Cancellation & Missed Appointment Policy
I require 24 hours advance notice to cancel your appointment. If I do not receive notice within 24 hours by voicemail or email, you will be responsible for 100% of the session fee which is equal to $100.
Contacting Me/After-Hours Emergencies
I am often not immediately available by telephone. While I am usually in my office between 3 PM and 8 PM Tuesdays and Wednesdays and between 8 AM and 1 PM Saturdays, I will not answer the phone when I am with a patient. When I am unavailable, my telephone is answered by an answering machine that I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform me of some times when you will be available. In emergencies, you can call me at any time but I may not answer or be able to respond quickly. If you are unable to reach me and feel that you can’t wait for me to return your call, contact your family physician or the nearest emergency room and ask for the psychologist or 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.
If you are experiencing a medical/mental health crisis and feel unable to keep yourself safe or cannot keep others safe, call 911 or go directly to the nearest emergency room.
Patient/Client Contact Policy
I need to be able to reach you regarding appointments, scheduling, and business changes or issues. You will provide a phone number and email address where you can be reached and where it is acceptable to leave messages regarding appointments, scheduling, and business matters.
I will not leave details related to your mental health on your voicemail. If you email me questions related to your mental health or protected health information, I will respond via email to the questions you ask and this could include a discussion of your mental health or protected health information. I cannot guarantee the security of electronic transmission of email through my email server (Gmail) or through yours and caution you to email sensitive information at your own risk.
Electronic Storage of Data
I offer online therapy appointments through a secure and HIPAA compliant portal called Wecounsel. I also store patient records within the WeCounsel software which is an encrypted and secure cloud-based storage and is HIPAA compliant. You can read more about Wecounsel at www.wecounsel.com.
Limits on Confidentiality
I have provided you with access to my Privacy Practices which discuss how I will use your protected health information and protect your privacy. There are limits to confidentiality regarding your safety and the safety of others and requirements for reporting that I must follow as a mandatory reporter in the State of Iowa. Limitations on Confidentiality include:
- If I am concerned you are a danger to yourself or another person(s), I am required and lawfully permitted to take steps to protect your health and safety and the health and safety of others to whom you pose a risk/threat. This may include but is not limited to: calling the police; contacting your family members; and contacting the person(s) who may be in danger due to your condition.
- If you disclose that you have engaged in abuse of a child or a dependent adult, I am required as a Mandatory reporter in the State of Iowa to call the Department of Human Services and submit a verbal and written report.
- If a court of law subpoenas my records or legally compels testimony and I am unable to deny their request.
- I seek consultation from professional colleagues to improve the quality of the services I provide. When engaged in consultation, I may discuss details of your diagnosis and treatment plan but will not disclose your identifying information.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS NOTICE CAREFULLY.
Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, and the NASW Code of Ethics. It also describes your rights regarding how you may gain access to and control your PHI.
We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices. We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, sending a copy to you in the mail upon request or providing one to you at your next appointment.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment. Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant only with your authorization.
For Payment. We may use and disclose PHI so that we can receive payment for the treatment services provided to you. This will only be done with your authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.
For Health Care Operations. We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI. For training or teaching purposes PHI will be disclosed only with your authorization.
Required by Law. Under the law, we must disclose your PHI to you upon your request. In addition, we must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule.
Without Authorization. Following is a list of the categories of uses and disclosures permitted by HIPAA without an authorization. Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of situations.
As a social worker licensed in Iowa and as a member of the National Association of Social Workers, it is our practice to adhere to more stringent privacy requirements for disclosures without an authorization. The following language addresses these categories to the extent consistent with the NASW Code of Ethics and HIPAA.
Child Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of child abuse or neglect.
Judicial and Administrative Proceedings. We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.
Deceased Patients. We may disclose PHI regarding deceased patients as mandated by state law, or to a family member or friend that was involved in your care or payment for care prior to death, based on your prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person’s estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.
Medical Emergencies. We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as reasonably practicable after the resolution of the emergency.
Family Involvement in Care. We may disclose information to close family members or friends directly involved in your treatment based on your consent or as necessary to prevent serious harm.
Health Oversight. If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payors based on your prior consent) and peer review organizations performing utilization and quality control.
Law Enforcement. We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.
Specialized Government Functions. We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.
Public Health. If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.
Public Safety. We may disclose your PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Research. PHI may only be disclosed after a special approval process or with your authorization.
Fundraising. We may send you fundraising communications at one time or another. You have the right to opt out of such fundraising communications with each solicitation you receive.
Verbal Permission. We may also use or disclose your information to family members that are directly involved in your treatment with your verbal permission.
With Authorization. Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization. The following uses and disclosures will be made only with your written authorization: (i) most uses and disclosures of psychotherapy notes which are separated from the rest of your medical record; (ii) most uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI; and (iv) other uses and disclosures not described in this Notice of Privacy Practices.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer at:
Quad City Women’s Therapy
Attn: Annika O’Melia
2550 Middle Road, Suite 316
Bettendorf, Iowa 52722.
- Right of Access to Inspect and Copy. You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a “designated record set”. A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable, cost-based fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.
- Right to Amend. If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.
- Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12-month period.
- Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.
- Right to Request Confidential Communication. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request. We will not ask you for an explanation of why you are making the request.
- Breach Notification. If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
- Right to a Copy of this Notice. You have the right to a copy of this notice.
If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at 2550 Middle Road, Suite 316 Bettendorf, Iowa 52722 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.
The effective date of this Notice is August 2017.
Professional Records Policy
The laws and standards of my profession require that I keep treatment records. You are entitled to receive a copy of the records unless I believe that seeing them would be emotionally damaging, in which case I will be happy to send them to a mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. I recommend that you review them in my presence so that we can discuss the contents. Patients will be charged an appropriate fee for any time spent in preparing information requests.
Credit Card Authorization
As a convenience for both parties, a credit card may be kept on file in an encrypted manner. If you provide permission with a signature, you will provide a credit card at the onset of treatment for future copays, deductibles or no show/late cancel fees to be kept encrypted in the electronic system eliminating billing. Please choose the maximum amount you are authorizing without contacting the responsible party (must be at least $150.00 in the event of a no show/late cancellation fee), and the method of how you are best alerted with a receipt notification (mail or email). You also may revoke this at any time, or agree to provide updated information as necessary.
Name of Client: ____________________________
Name on Card: _____________________________
Billing Street Address: ________________________
Maximum Amount Authorized: __________________