NEUROFEEDBACK SERVICES AGREEMENT

Welcome tomy practice. This document (the Agreement) contains important information aboutmy professional services and business policies. It also contains summaryinformation about the Health Insurance Portability and Accountability Act(HIPAA), a federal law that provides new privacy protections and new patientrights with regard to the use and disclosure of your Protected HealthInformation (PHI) used for the purpose of treatment, payment, and health careoperations.  HIPAA requires that Iprovide you with a Notice of Privacy Practices (the Notice) for use anddisclosure of PHI for treatment, payment and health care operations. TheNotice, which is attached to this Agreement, explains HIPAA and its applicationto your personal health information in greater detail. The law requires that Iobtain your signature acknowledging that I have provided you with thisinformation at. Although these documents are long and sometimes complex, it isvery important that you read them carefully. We can discuss any questions youhave about the procedures. When you sign this document, it will also representan agreement between us. You may revoke this Agreement in writing at anytime.  That revocation will be binding onme unless I have taken action in reliance on it; if there are obligationsimposed on me by your health insurer in order to process or substantiate claimsmade under your policy; or if you have not satisfied any financial obligationsyou have incurred.

NEUROFEEDBACK SERVICES

Neurofeedback is direct training ofbrain function, by which the brain learns to function

more efficiently.  Neurofeedback is also called EEG biofeedback,because it is based on electrical brain activity, the electroencephalogram, orEEG.  Neurofeedback is training inself-regulation.  It is simplybiofeedback applied directly to the brain. Self-regulation is a necessary part of good brain function.  Self-regulation training allows the centralnervous system to function better.

Neurofeedback training can improveattention, cognitive abilities and emotional regulation.  It can help to reduce or eliminate a numberof common symptoms such as anxiety, stress reactions, depression, sleepproblems, headaches and migraines and emotional distress Neurofeedback can havebenefits and risks.

Our firstsessions will involve an evaluation of your needs. By the end of theevaluation, I will be able to offer you some first impressions of what our workwill include and a treatment plan to follow. If you decide to continue with Neurofeedback,you should evaluate this information along with your own opinions of whetheryou feel comfortable working with me. Neurofeedback involves a large commitmentof time and money so you should be very careful about the therapist you select.If you have questions about these procedures, we should discuss them wheneverthey arise. If your doubts persist, I will be happy to help you set up ameeting with another mental health professional for a second opinion.

MEETINGS

I normallyconduct an evaluation that will lasts from 2 sessions. During this time, we canboth decide if Neurofeedback is the best service that you need in order to meetyour treatment goals. If treatment is begun, we will usually schedule two30-minute sessions per week at a time we agree on, although some sessions maybe longer or more frequent. Once anappointment hour is scheduled, you will be expected to pay for it unless youprovide 24 hours [1day] advance notice of cancellation [unless we bothagree that you were unable to attend due to circumstances beyond your control].It is important to note that insurance companies do not provide reimbursementfor cancelled sessions. [If it is possible, I will try to find another timeto reschedule the appointment.]

PROFESSIONAL FEES

The fee forthe initial evaluation and first session is $350. The 30-minute session fee forNeurofeedback is $125 per session. The fee for 20 sessions is $2000 and must bepaid prior to beginning treatment.  Iffor some reason you do not complete the 20 session course of treatment your feewill be prorated at the $125 per 30 minute session rate. In addition to weeklyappointments, I charge $250 per hour for other professional services you mayneed, though I will break down the hourly cost if I work for periods of lessthan one hour. Other services include report writing, telephone conversationslasting longer than 10 minutes, consulting with other professionals with yourpermission, preparation of records or treatment summaries, and the time spent performingany other service you may request of me. If you become involved in legalproceedings that require my participation, you will be expected to pay for allof my professional time, including preparation and transportation costs, evenif I am called to testify by another party. [Because of the difficulty of legalinvolvement, I charge $300 per hour for preparation and attendance at any legalproceeding.]

CONTACTING ME

Due to mywork schedule, I am often not immediately available by telephone. While I amusually in my office between 9 AM and 5 PM, I probably will not answer thephone when I am with a patient. When I am unavailable, my telephone is answeredby voice mail. [that I monitor frequently]. I will make every effort to returnyour call on the same day you make it, with the exception of weekends andholidays. If you are difficult to reach, please inform me of some times whenyou will be available. [In emergencies, you can reach me through my emergencyvoice mail box.] If you are unable to reach me and feel that you can’t wait forme to return your call, contact your family physician or the nearest emergencyroom and ask for the psychologist [psychiatrist] on call. If I will beunavailable for an extended time, I will provide you with the name of a colleagueto contact, if necessary.

LIMITS ON CONFIDENTIALITY

The lawprotects the privacy of all communications between a patient and apsychologist. In most situations, I can only release information about yourtreatment to others if you sign a written Authorization form that meets certainlegal requirements imposed by HIPAA. There are other situations that requireonly that you provide written, advance consent. Your signature on thisAgreement provides consent for those activities, as follows:

·        I may occasionally find it helpful to consult otherhealth and mental health professionals about a case. During a consultation, Imake every effort to avoid revealing the identity of my patient. The otherprofessionals are also legally bound to keep the information confidential. Ifyou don’t object, I will not tell you about these consultations unless I feelthat it is important to our work together. I will note all consultations inyour Clinical Record (which is called “PHI” in my Notice of Psychologist’sPolicies and Practices to Protect the Privacy of Your Health Information). 

·        You should be aware that I practice with other mentalhealth professionals and that I employ administrative staff. In most cases, Ineed to share protected information with these individuals for both clinicaland administrative purposes, such as scheduling, billing and quality assurance.All of the mental health professionals are bound by the same rules ofconfidentiality. All staff members have been given training about protectingyour privacy and have agreed not to release any information outside of thepractice without the permission of a professional staff member.

·        I also have contracts with my accountant andcollection agency.  As required by HIPAA,I have a formal business associate contract with this/these business(as), inwhich it/they promise to maintain the confidentiality of this data except asspecifically allowed in the contract or otherwise required by law. If you wish,I can provide you with the names of these organizations and/or a blank copy ofthis contract.

·        Disclosures required by health insurers or to collectoverdue fees are discussed elsewhere in this Agreement.

There are some situations whereI am permitted or required to disclose information without either your consentor Authorization:

·        If you are involved in a court proceeding and arequest is made for information concerning your diagnosis and treatment, suchinformation is protected by the psychologist-patient privilege law. I cannotprovide any information without your (or your legal representative’s) writtenauthorization, or a court order, or if I receive a subpoena of which you havebeen properly notified and you have failed to inform me that you oppose thesubpoena.  If you are involved in orcontemplating litigation, you should consult with your attorney to determinewhether a court would be likely to order me to disclose information.

·        If a government agency is requesting theinformation for health oversight activities, within its appropriate legalauthority, I may be required to provide it for them.

·        If a patient files a complaint or lawsuitagainst me, I may disclose relevant information regarding that patient in orderto defend myself.

·        If a patient files a worker’s compensationclaim, and I am providing necessary treatment related to that claim, I must,upon appropriate request, submit treatment reports to the appropriate parties,including the patient’s employer, the insurance carrier or an authorizedqualified rehabilitation provider.

There are some situations inwhich I am legally obligated to take actions, which I believe are necessary toattempt to protect others from harm and I may have to reveal some informationabout a patient’s treatment. These situations are unusual in my practice.

§ If I know, or have reason to suspect, that achild under 18 is abused, abandoned, or neglected by a parent, legal custodian,caregiver, or any other person responsible for the child’s welfare, the lawrequires that I file a report with the Department of Child and Family Services.Once such a report is filed, I may be required to provide additionalinformation.

§ If I know or have reasonable cause to suspect,that a vulnerable adult has been or is being abused, neglected, or exploited,the law requires that I file a report with the central abuse hotline.  Once such a report is filed, I may berequired to provide additional information.

§ If I believe that there is a clear and immediateprobability of physical harm to the patient, to other individuals, or tosociety, I may be required to disclose information to take protective action,including communicating the information to the potential victim, and/orappropriate family member, and/or the police or seeking hospitalization of thepatient.

If such a situation arises, Iwill make every effort to fully discuss it with you before taking any actionand I will limit my disclosure to what is necessary.

While thiswritten summary of exceptions to confidentiality should prove helpful ininforming you about potential problems, it is important that we discuss anyquestions or concerns that you may have now or in the future. The lawsgoverning confidentiality can be quite complex, and I am not an attorney. Insituations where specific advice is required, formal legal advice may beneeded.

PROFESSIONAL RECORDS

The laws and standards of myprofession require that I keep Protected Health Information about you in yourClinical Record. It includes information about your reasons for seekingtherapy, a description of the ways in which your problem impacts on your life,your diagnosis, the goals that we set for treatment, your progress towardsthose goals, your medical and social history, your treatment history, any pasttreatment records that I receive from other providers, reports of anyprofessional consultations, your billing records, and any reports that havebeen sent to anyone, including reports to your insurance carrier.  Except in unusual circumstances thatdisclosure would physically endanger you and/or others or makes reference toanother person (other than a health care provider) and I believe that access isreasonably likely to cause substantial harm to such other person, you mayexamine and/or receive a copy of your Clinical Record, if you request it inwriting. Because these are professional records, they can be misinterpretedand/or upsetting to untrained readers. For this reason, I recommend that youinitially review them in my presence, or have them forwarded to another mentalhealth professional so you can discuss the contents. [I am sometimes willing toconduct this review meeting without charge.] In most circumstances, I amallowed to charge a copying fee of $1.00 per page (and for certain otherexpenses). I may withhold copies of your records until payment of the copyingfees has been made. If I refuse your request for access to your records, youhave a right of review, which I will discuss with you upon request.

PATIENT RIGHTS

HIPAA provides you with severalnew or expanded rights with regard to your Clinical Records and disclosures ofprotected health information. These rights include requesting that I amend yourrecord; requesting restrictions on what information from your Clinical Recordsis disclosed to others; requesting an accounting of most disclosures ofprotected health information that you have neither consented to nor authorized;determining the location to which protected information disclosures are sent;having any complaints you make about my policies and procedures recorded inyour records; and the right to a paper copy of this Agreement, the attachedNotice form, and my privacy policies and procedures. I am happy to discuss anyof these rights with you.

MINORS & PARENTS

Patientsunder 18 years of age who are not emancipated and their parents should be awarethat the law may allow parents to examine their child’s treatment records.Children between 13 and 17 may independently consent to (and control access tothe records of) diagnosis and treatment in a crisis situation. Because privacyin psychotherapy is often crucial to successful progress, particularly withteenagers, and parental involvement, is also essential, it is usually my policyto request an agreement with minors [over 12] and their parents aboutaccess to information. This agreement provides that during treatment, I willprovide parents only with general information about the progress of thetreatment, and the patient’s attendance at scheduled sessions. I will alsoprovide parents with a summary of their child’s treatment when it is complete.Any other communication will require the child’s Authorization, unless I feelthat the child is in danger or is a danger to someone else, in which case, Iwill notify the parents of my concern. Before giving parents any information, Iwill discuss the matter with the child, if possible, and do my best to handleany objections he/she may have.   

BILLING AND PAYMENTS

You will beexpected to pay for each session at the time it is held, unless we agreeotherwise or unless you have insurance coverage that requires anotherarrangement. Payment schedules for other professional services will be agreedto when they are requested. [In circumstances of unusual financial hardship, Imay be willing to negotiate a fee adjustment or payment installment plan.]

If youraccount has not been paid for more than 60 days and arrangements for paymenthave not been agreed upon, I have the option of using legal means to secure thepayment. This may involve hiring a collection agency or going through smallclaims court which will require me to disclose otherwise confidentialinformation. In most collection situations, the only information I releaseregarding a patient’s treatment is his/her name, the nature of servicesprovided, and the amount due.  [If suchlegal action is necessary, its costs will be included in the claim.]

INSURANCE REIMBURSEMENT

If you havea health insurance policy, it may provide some coverage for our initial meetingand evaluation.  However it has been ourexperience that most insurance companies do not cove Neurofeedback services Iwill fill out forms and provide you with whatever assistance I can in helpingyou receive the benefits to which you are entitled; however, you (not yourinsurance company) are responsible for full payment of my fees. It is veryimportant that you find out exactly what services your insurance policy covers.

You should carefully read thesection in your insurance coverage booklet that describes mental healthservices. If you have questions about the coverage, call your planadministrator. Of course, I will provide you with whatever information I canbased on my experience and will be happy to help you in understanding theinformation you receive from your insurance company. If it is necessary toclear confusion, I will be willing to call the company on your behalf.

Due to therising costs of health care, insurance benefits have increasingly become morecomplex. It is sometimes difficult to determine exactly how much mental healthcoverage is available. “Managed Health Care” plans such as HMOs and PPOs oftenrequire authorization before they provide reimbursement for mental healthservices. These plans are often limited to short-term treatment approachesdesigned to work out specific problems that interfere with a person’s usuallevel of functioning. It may be necessary to seek approval for more therapyafter a certain number of sessions. While much can be accomplished inshort-term therapy, some patients feel that they need more services afterinsurance benefits end. [Some managed-care plans will not allow me to provideservices to you once your benefits end. If this is the case, I will do my bestto find another provider who will help you continue your psychotherapy.]

You should also be aware thatyour contract with your health insurance company requires that I provide itwith information relevant to the services that I provide to you. I am requiredto provide a clinical diagnosis. Sometimes I am required to provide additionalclinical information such as treatment plans or summaries, or copies of yourentire Clinical Record. In such situations, I will make every effort to releaseonly the minimum information about you that is necessary for the purposerequested. This information will become part of the insurance company files andwill probably be stored in a computer. Though all insurance companies claim tokeep such information confidential, I have no control over what they do with itonce it is in their hands. In some cases, they may share the information with anational medical information databank. I will provide you with a copy of anyreport I submit, if you request it. By signing this Agreement, you agree that Ican provide requested information to your carrier.

Once wehave all of the information about your insurance coverage, we will discuss whatwe can expect to accomplish with the benefits that are available and what willhappen if they run out before you feel ready to end your sessions. It isimportant to remember that you always have the right to pay for my servicesyourself to avoid the problems described above [unless prohibited by contract].

YOURSIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITSTERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAANOTICE FORM DESCRIBED ABOVE

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Rev. 04/07