New Client Information Packet
If you have scheduled an appointment, you may wish to download this New Client Information Packet and bring it with you to your first appointment.
Please know that if any of the questions asked on this form cause you any discomfort, it is perfectly ok to leave those questions blank. Because the completed form may contain sensitive information about you, it is not editable online. It is best not to email this form to me, as your privacy cannot be protected during email transmission. Rather, please bring the competed form with you to your first appointment. You can download this form by clicking here.
Confidentiality and Privacy Policy
In summary of important features of the Confidentiality/Privacy Practices and HIPAA law, you can be assured that our conversations and my records will be held in the strictest confidence, as protected information according to my professional code of ethics and by law. A few exceptions to this rule exist, which are important to understand. Confidentiality is not guaranteed in cases of: 1) a person’s intent to harm him/herself or intent to harm another; and 2) when there is current or future threat of abuse of a child or elderly person. Also, in rare circumstances, a court may be able to order a professional therapist to release information. Please know that this is an extremely rare circumstance. In any other situation, you will be asked to sign a “Consent to Release” form when you desire that certain information be released to another party.
You
have the right to receive a “Good Faith
Estimate” explaining how much your
health care will cost
Under the law, health care
providers need to give patients who
don’t have certain types of health care coverage
or who are not using certain
types of health care coverage an estimate of
their bill for health care
items and services before those items or services
are provided.
•
You
have the right to receive a Good Faith Estimate for
the total expected cost
of any health care items or services upon request or
when scheduling such items
or services. This includes related costs like
medical tests, prescription
drugs, equipment, and hospital fees.
•
If
you schedule a health care item or service at least
3 business days in
advance, make sure your health care provider or
facility gives you a Good Faith
Estimate in writing within 1 business day after
scheduling. If you schedule a
health care item or service at least 10 business
days in advance, make sure
your health care provider or facility gives you a
Good Faith Estimate in
writing within 3 business days after scheduling. You
can also ask any health
care provider or facility for a Good Faith Estimate
before you schedule an item
or service. If you do, make sure the health care
provider or facility gives you
a Good Faith Estimate in writing within 3 business
days after you ask.
•
If
you receive a bill that is at least $400 more for
any provider or facility
than your Good Faith Estimate from that provider or
facility, you can dispute
the bill.
•
Make
sure to save a copy or picture of your Good Faith
Estimate and the bill.
For
questions or more information
about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises/consumers,
email
FederalPPDRQuestions@cms.hhs.gov,
or call 1800-985-3059.