Forms and What to Expect
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At Bloom Therapeutics, we are committed to treating and using protected health information responsibly. This notice describes the procedures we use to protect your information, and the circumstances under which your personal health information may be disclosed. It also describes your rights as they relate to this information. The rules for confidentiality of mental health records are recorded in the Illinois Mental Health and Developmental Disabilities Confidentiality Act and in the privacy rules of the Health Insurance Portability and Accountability Act. We strongly suggest you review these provisions in order to fully understand our procedures and your rights.
We strive to protect your personal health information.
At Bloom Therapeutics, every effort is made to keep your personal health information private. Some of our procedures will be evident to you. For example, when you call to discuss an issue with office staff, we may ask you for some piece of identifying information to confirm your identity. Others happen behind the scenes. Computer data is password protected at the workstations and every effort is made to prevent others from viewing your personal health information. If you have any concerns about your privacy, please bring them to our attention.
You are entitled to copy or review your mental health records.
You have the right to inspect and/or copy your health record. Emails that include clinical information may be included as part of the record. If, after reviewing your record, you believe that any statement is in error, you have a right to request that the person who made the entry make a correction. Anytime you request a revision, your request and the action taken must be noted in the record. If a professional chooses to stand by a statement with which you disagree, you have the right to add a written amendment stating why you believe the entry is in error. Any time that section of the record is released, your amendment must be included.
The following individuals can access a mental health record without written authorization.
an adult recipient of services; 2) the parent or guardian of a child who is under 12 years of age; 3) the recipient if he is 12 years of age or older; 4) the parent or guardian of a recipient who is at least 12 but under 18, if the recipient does not object or if the therapist does not find that there is a compelling reason for denying access, but nothing in this statement is intended to prevent a parent or guardian of a child who is at least 12 but under 18 from requesting and receiving the following information: current physical and mental condition, diagnosis, treatment needs, services provided, and services needed; 5) a legal guardian of a recipient who is 18 or over; 6) an attorney, guardian ad litem, or power of attorney or other person who is legally authorized to access the records. We are happy to provide you with assistance in understanding the record.
In the following circumstances, we may release your records without your permission.
There are circumstances that impose limitations on a client’s right or ability to maintain privileged communication. A therapist may disclose a record without consent: 1) to a supervisor, consulting therapist, or member of the staff team participating in the provision of services, a record custodian, or a person acting under the supervision of the therapist; 2) when a therapist believes a clear and immediate danger exists to one or more persons; 3) when disclosure is necessary to provide a recipient with emergency medical care or access to needed benefits when the recipient is not in a condition to waive or assert his or her rights; 4) when abuse or neglect of a child is suspected; 5) when a therapist is consulting with an employer, attorney, professional liability company, or other relevant business associate concerning the care or treatment he or she has provided, including disclosure to business associates who may help us pursue payment (but each of these recipients shall be held to HIPAA privacy standards and may not redisclose the information); 6) when a recipient introduces his or her mental condition or any aspect of services received for such condition as an element of a claim or defense; and, 7) in certain other legal situations where the court has decided that disclosure is directly relevant to the issue being investigated. Furthermore, as part of the Illinois Firearm Concealed and Carry Act (PA98-063), clinicians are required to notify the Illinois Department of Human Services of anyone who is determined to be a “clear and present danger” to themselves or others or determined to be developmentally or intellectually disabled.
Additional rights.
You have the right to request restrictions on certain uses and disclosure of personal health information. However, Bloom Therapeutics is not required to agree to a requested restriction, and in some situations, is prohibited by law from agreeing to a requested restriction. You have the right to request and receive an accounting of disclosures that we make to other individuals. Bloom Therapeutics reserves the right to change the terms of its Privacy Policy and to make the new Policy provisions effective for all personal health information that it maintains. You will be notified of any changes to the Policy. If you believe your privacy has been violated, bring the matter to the head of Bloom Therapeutics. If you have a dispute that cannot be resolved, please contact the Privacy Officer, Katie Szarzynski or her designee, at (815) 567-3168. You may also file a complaint with the Office for Civil Rights, U.S. Dept of Health & Human Services, 200 Independence Ave; S.W., Room 509F, HHH Building, Washington, DC 20201. There can be no retaliation for filing a complaint.
Your signature below indicates consent to treatment and that you have read the information in this document and agree to abide by its terms during our professional relationship.
No Surprises Act
Under Section 2799B-6 of the Public Health Service Act, health care providers and health care facilities are required to inform individuals who are not enrolled in a plan or coverage or a Federal health care program, or not seeking to file a claim with their plan or coverage both orally and in writing of their ability, upon request or at the time of scheduling health care items and services, to receive a “Good Faith Estimate” of expected charges.
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost
Under the law, health care providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your health care provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your health care provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate. For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises
Informed Consent for Psychotherapy
General Information
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by filling in the checkbox at the end of this document.
Client/Therapist Relationship
You and your Therapist have a professional relationship existing exclusively for therapeutic treatment. This relationship functions most effectively when it remains strictly professional and involves only the therapeutic aspect. Your therapist can best serve your needs by focusing solely on therapy and avoiding any type of social or business relationship. Gifts are not appropriate, nor are any sort of trade of service for service.
The Therapeutic Process
You have taken a very positive step by deciding to seek therapy. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Remembering unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings of anger, depression, anxiety, etc. There are no miracle cures. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
After you’re scheduled with a therapist, you will be given access to a virtual client portal where you're able to complete paperwork prior to your first session, unless otherwise specified.
Therapy sessions are approximately 53 minutes long. The first few sessions, the clinician will be completing an evaluation, in order to identify a diagnostic impression and treatment goals for therapy. This process may take one or more sessions. These first sessions are also a good time to discuss any questions you may have about therapy, Bloom Therapeutics policies, procedures, billing, etc.
Should you choose not to follow the plan of treatment provided to you by your Therapist, services to you may be terminated.
The goal is to provide the most effective therapeutic experience available to you. If at any time you feel that you and your current Therapist are not a good fit, please discuss this matter with your therapist to determine if transferring to a more suitable therapist is right for you. If you and your therapist decide that other services would be more appropriate you will be assisted in finding a provider to meet your needs.
Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts themselves in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Emergencies
You may encounter a personal emergency which will require prompt attention. In this event, you may contact the Therapy Office regarding the nature or urgency of the circumstances. I will make every attempt to schedule you as soon as possible or to offer other options. Because clients may be scheduled back-to-back, it is not always possible to return a call immediately. However, I will make every effort to respond to your emergency in a timely manner. If your emergency arises after hours or on the weekend, please follow the message on the office voicemail. If you are experiencing a life threatening emergency, call 911 or have someone take you to your nearest emergency room for help. When your Therapist is out of town, you will be advised and given the name of an on-call provider.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you, but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.
PRACTICE POLICIES
APPOINTMENTS AND CANCELLATIONS Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the $75 fee if cancellation is less than 24 hours before your scheduled appointment time. If you are late for a session, you may lose some of that session time.
The standard meeting time for psychotherapy is 60 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 60-minute session needs to be discussed with the therapist in order for time to be scheduled in advance. The therapist may determine a standard meeting time to be shorter for a child client due to developmental age for engagement in a therapy session.
PAYMENT/FINANCIAL POLICY A $25.00 service charge will be charged for any checks returned for any reason for special handling.
This practice requires a credit card on file to securely streamline payments for patient financial responsibilities not covered by insurance, such as copays, deductibles, or missed appointment fees. Your card is charged only after insurance processes claims, reducing administrative costs and paper billing.
Payments are due at the time of service. All copays, deductibles, co-insurance, self-pay charges, and past due balances are due at the time of service. If you arrive without your copayment, we may ask you to reschedule. We do accept cash, checks and credit cards.
Billing insurance. We are happy to bill your insurance company as a courtesy to you. Should there be a balance due after insurance processing you will be sent a bill and your credit card on file will be charged. All client responsibility balances are due within 30 days of receipt.
Self Pay. If you do not have insurance coverage, you will be asked to pay in full at time of service.
Our Responsibility to Report Non-Compliance. It is our obligation under many of the insurance contracts to report patients who repeatedly refuse to pay co-payments/deductibles at time of service, or who repeatedly “no show” for scheduled appointments.
Divorce or Custody Cases: The parent who brings a child to the office for care is responsible for any payment at the time of service no matter if the account is self-pay, participating insurance, or non participating insurance. We do not honor divorce specifics (i.e., percentage of financial responsibility). Applicable co-payments, coinsurance and/or deductible are due at time of service.
Collection: On any accounts that remain unpaid for longer than 90 days, we reserve the right to report delinquent accounts to credit bureaus, transfer accounts to third party collection agencies, assess collections and/or reasonable attorney’s/court costs, take other collection actions, and terminate you as a patient of our practice.
If you make an overpayment on your account, we will issue a refund only if there are no other outstanding debts on your account.
TELEPHONE ACCESSIBILITY If you need to contact your therapist between sessions, please leave a message on the office voice mail. Therapist is often not immediately available; however, will attempt to return your call within 24 hours or the next business day. Please note that virtual sessions are available; in the event that you are out of town, sick or need additional support, virtual sessions are available. If a true emergency situation arises, please call 911 or any local emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
ELECTRONIC COMMUNICATION and TELEMEDICINE The office utilizes services that are HIPAA compliant however I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or messaging for issues regarding scheduling or cancellations, I will do so. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.
Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of California. Under the California Telemedicine Act of 1996, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your therapist chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5) There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to therapy, better continuity of care, and reduction of lost work time and travel costs. Effective therapy is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Therapists may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the therapist's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the therapist not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the therapist.
MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.
TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for four consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT. I HAVE READ AND UNDERSTAND THE ABOVE FINANCIAL POLICY. I UNDERSTAND THAT CHARGES NOT COVERED BY MY INSURANCE COMPANY, AS WELL AS APPLICABLE CO-PAYMENTS, DEDUCTIBLES AND CO-INSURANCE ARE MY RESPONSIBILITY. I AUTHORIZE MY INSURANCE BENEFITS TO BE PAID DIRECTLY TO BLOOM THERAPEUTICS, PLLC.
Minors Outpatient Services Contract
(**ages of 12 and 17)
Clients between the ages of 12 and 17 have certain rights in terms of confidentiality and consenting to treatment. Any minor between 12 and 17 years old may request counseling services or psychotherapy on an outpatient basis and it does not require the consent of a parent or guardian for eight 90-minute sessions. If therapy is recommended to continue past the eight 90 minute sessions, consent of both parents.guardians would be required to continue counseling services, unless there is proof of sole custody outlined in a divorce decree or other legal document. In that case, only the parent with sole custody must sign the informed consent. If the minor does not allow for consent from a parent/guardian, then counseling services will be discontinued and referrals will be provided.
If a parent claims sole custody of a child/minor, then a copy of the most updated divorce decree or other legal document outlining parental responsibilities must be provided to the clinician and only that parent will be required to provide informed consent. The non-custodial parent may; however, be notified of the child’s involvement in therapy if deemed appropriate.
In terms of confidentiality, parents/guardians have the right to request and inspect their child’s record, current physical and mental condition, diagnosis, treatment needs, services provided, and services needed, including medication, if any. That said, clients between 12 and 17 have the right to deny a parent/guardian access to inspect their records, as long as the therapist finds the reasons to be compelling to deny access.
Similar guidelines apply to communication regarding a minor’s treatment. It is recommended that clients between the ages of 12 and 17 discuss these limits and expectations with their clinicians and parents/guardians early in the therapeutic process. When possible, the clinician will discuss any information with the client prior to sharing with the parent/guardian and navigate through any objection the client may have.
Client’s between the ages of 12 and 17 may request to privately review their records with the assistance of their clinician, free of charge.
Clients between the ages of 12 and 17 must co-sign any Release of Information completed for the clinician to communicate with any other providers or individuals who are part of the client’s treatment. Additionally, they have the right to revoke the Release of Information at any time.
Bloom Therapeutics utilizes telehealth services for client’s safety and convenience, if applicable. I understand that telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations. I understand the following with respect to telemental health:
CONSENT FOR TELEHEALTH CONSULTATION
I understand that my health care provider wishes me to engage in a telehealth consultation.
My health care provider explained to me how the video conferencing technology that will be used to affect such a consultation will not be the same as a direct client/health care provider visit due to the fact that I will not be in the same room as my provider.
I understand that a telehealth consultation has potential benefits including easier access to care and the convenience of meeting from a location of my choosing.
I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
I understand that I have the right to withdraw consent at any time without affecting my right to future care, services, or program benefits to which I would otherwise be entitled.
I understand that there are risks and consequences associated with telemental health, including but not limited to, disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and/or limited ability to respond to emergencies.
I understand that there will be no recording of any kind of the online sessions by either party. All information disclosed within sessions and written records pertaining to those sessions are confidential and may not be disclosed to anyone without written authorization, except where the disclosure is permitted and/or required by law.
I understand that the privacy laws that protect the confidentiality of my protected health information (“PHI”) also apply to telemental health unless an exception to confidentiality applies.
I understand that if I am having suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telemental health services are not appropriate and a higher level of care is required.
I understand that during a telemental health session, we could encounter technical difficulties resulting in service interruptions. If this occurs, end and restart the session. If we are unable to reconnect within ten minutes, I will call Bloom Therapeutics at (PHONE NUMBER).
CONSENT TO USE THE TELEHEALTH BY SIMPLEPRACTICE SERVICE
Telehealth by SimplePractice is the technology service we will use to conduct telehealth videoconferencing appointments. It is simple to use and there are no passwords required to log in. By signing this document, I acknowledge:
Telehealth by SimplePractice is NOT an Emergency Service and in the event of an emergency, I will use a phone to call 911.
Though my provider and I may be in direct, virtual contact through the Telehealth Service, neither SimplePractice nor the Telehealth Service provides any medical or healthcare services or advice including, but not limited to, emergency or urgent medical services.
The Telehealth by SimplePractice Service facilitates videoconferencing and is not responsible for the delivery of any healthcare, medical advice or care.
I do not assume that my provider has access to any or all of the technical information in the Telehealth by SimplePractice Service – or that such information is current, accurate or up-to-date. I will not rely on my health care provider to have any of this information in the Telehealth by SimplePractice Service.
To maintain confidentiality, I will not share my telehealth appointment link with anyone unauthorized to attend the appointment.
By signing this form, I certify:
That I have read or had this form read and/or had this form explained to me.
That I fully understand its contents including the risks and benefits of the procedure(s).
That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.
BY SIGNING BELOW I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.