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Terms and Policy

Telehealth Policy

                                                                                     Telehealth Informed Consent


As a client receiving behavioral services from Amy B. Faust, LPC (practitioner) through telehealth methods, I understand:


Telehealth is the delivery of behavioral health services using interactive technologies (audio, video or other electronic communications) between a provider and a client that are not in the same physical location. The interactive technologies used in telehealth incorporate network and software security protocols to protect the confidentiality of patient information transmitted via any electronic channel. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. Electronic systems used will incorporate network and software security protocols to protect the privacy and security of health information and imaging data, and will include measures to safeguard the data to ensure its integrity against intentional or unintentional corruption.


This service is provided by technology (included but not limited to video, phone, text and email) and may involve direct face to face communication. There are benefits and limitations to this service. I will need access to, and familiarity with, the appropriate technology in order to participate in the service provided. The exchange of information will not be direct and any paperwork exchanged will likely be provided through electronic means or through postal delivery. During your virtual care consultation, details of your medical history and personal health information may be discussed with you or your behavioral health care professionals through the use of interactive video, audio or other telecommunications technology.


If a need for direct, face to face services arises, it is my responsibility to speak with Amy B. Faust, LPC regarding this need.  It is also my responsibility to then contact practitioners in my area who may provide such services.  I understand that I may be provided a list of referrals by Amy B. Faust, LPC and that to contact anyone she suggests is my choice and that I am under no obligation to speak with anyone on said list.  I recognize that I may also contact my primary care provider if preferred, or in the case that the suggested referrals are not available. I understand that an opening may not be immediately available in either my primary care provider's office, or in the office of a recommended referral.


I may decline any telehealth services at any time without jeopardizing my access to future care, services or benefits. I understand that a variety of alternative methods of mental health care may be available to me, and that I may choose one or more of these at any time. 


Telehealth services rely on technology, which allows for greater convenience in service delivery. There are risks in transmitting information over technology that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. My practitioner and I will regularly reassess the appropriateness of continuing to deliver services to me through the use of the technologies we have agreed upon today, and modify our plan as needed.


In emergencies, in the event of disruption of services, or for routine or administrative reasons, it may be necessary to communicate by other means.  I have provided Amy B. Faust, LPC with a direct phone number(s), email address(es), residential address, and emergency contact(s) should the need arise to communicate via other methods.  I understand that should we encounter a disruption in services, due to technological failure, or any other reason, Amy B. Faust, LPC will attempt to reach me via one of the other methods I have provided, at her discretion.  


My practitioner will respond to communications and routine messages within 48 hours on business days or on the next business day following weekends, holidays, or vacations.  I recognize that contingent upon my purchased plan and/or agreement, I may be billed additionally for said services.


It is my responsibility to maintain privacy on the client end of communication. Insurance companies, those authorized by the client, and those permitted by law may also have access to records or communications.


I will take the following precautions to ensure that my communications are directed only to my behavioral health practitioner or other designated individuals: Double check email addresses; double check phone numbers; double check to whom email is sent (reply vs reply all).


My communication with my behavioral health practitioner will be stored in the following manner: In compliance with HIPAA regulations in secured file cabinets and/or secured electronic medical record files.


The laws and professional standards that apply to in-person behavioral services also apply to telehealth services. This document does not replace other agreements, contracts, or documentation of informed consent.


I agree to participate in technology-based consultation and other health-care related information exchanges with Amy B. Faust,LPC, a behavioral healthcare practitioner ("practitioner"). This means that I authorize information related to my medical and behavioral health to be electronically transmitted in the form of images and data through an interactive video connection, phone connection or secured messaging system, to and from the above-named practitioner, other persons involved in my health care, and the staff operating the consultation equipment. It may also mean that my private health information may be transmitted from my practitioner's mobile device to my own or from my device to that of my practitioner via an 'application' (abbreviated as "app").


I represent that I am using my own equipment to communicate and not equipment owned by another, and specifically not using my employer's computer or network. I am aware that any information I enter into an employer's computer can be considered by the courts to belong to my employer and my privacy may thus be compromised.


I understand that I will be informed of the identities of all parties present during the consultation or who have access to my personal health information and of the purpose for such individuals to have such access.


My health care practitioner has explained how the telehealth consultation(s) is performed and how it will be used for my treatment. My health care practitioner has also explained how the consultation(s) will differ from in-person services, including but not limited to, emotional reactions that may be generated by the technology.


I understand that it is my duty to inform Amy B. Faust, LPC of electronic interactions regarding my care that I may have with other health care providers.


In brief, I understand that Amy B. Faust, LPC will not be physically in my presence. Instead, we will see and hear each other electronically, or that other information such as information I enter into an "app" will be transmitted electronically to and from my practitioner and I. Regardless of the sophistication of today's technology, some information my practitioner would ordinarily get via in-person consultation may not be available in teleconsultation. I understand that such missing information could in some situations make it more difficult for my practitioner to understand my problems and to help me get better. My practitioner will be unable to physically touch me or to render any emergency assistance if I experience a crisis.


I understand that telehealth consultation(s) are a new form of treatment, in an area not yet fully validated by research, and that they have potential risks, possibly including some that are not yet recognized. Among the risks that are presently recognized is the possibility that the technology will fail before or during the consultation, that the transmitted information in any form will be unclear or inadequate for proper use in the consultation(s), and that the information will be intercepted by an unauthorized person or persons.


In rare instances, security protocols could fail, causing a breach of privacy of personal health information. I understand that a physical examination may be performed by individuals at my location at the request of the consulting practitioner.


I authorize the release of any information pertaining to me determined by my practitioner, my other health care practitioners or by my insurance carrier to be relevant to the consultation(s) or processing of insurance claims, including but limited to my name, Social Security number, birth date, diagnosis, treatment plan and other clinical or medical record information.


I understand that at any time, the consultation(s) can be discontinued either by me or by my designee or by my health care practitioners. I further understand that I do not have to answer any question I feel is inappropriate or whose answer I do not wish persons present to hear; that any refusal to participate in the consultation(s) or use of technology will not affect my continued treatment and that no action will be taken against me. I acknowledge, however, that diagnosis depends on information, and treatment depends on diagnosis, so if I withhold information, I assume the risk that a diagnosis might not be made or might be made incorrectly. Were that to happen, my telehealth-based treatment might be less successful than it otherwise would be, or it could fail entirely.


I also understand that, under the law and regardless of what form of communication I use in working with my practitioner, my practitioner may be required to report to the authorities information suggesting that I have engaged in behaviors that endanger others.


The alternatives to the consultation(s) have been explained to me, including their risks and benefits, as well as the risks and benefits of going without treatment. I understand that I can still pursue in-person consultations. I understand that telehealth consultation(s) does not necessarily eliminate my need to see a specialist in person, and I have received no guarantee as to the telehealth consultation's effectiveness.


I understand that my telehealth consultation(s) may be recorded and stored electronically as part of my medical records. The practitioner will inform me if this is to occur and the reasons for this being necessary. I understand that consultations, test results, and disclosures will be held in confidence subject to state and/or federal law. I understand that I am ordinarily guaranteed access to my medical records and that copies of records of consultation(s) are available to me on my written request. I also understand, however, that if my practitioner, in the exercise of professional judgment, concludes that providing my records to me could threaten the safety of a human being, myself or another person, he/she may rightfully decline to provide them. If such a request is made and honored, I understand that I retain sole responsibility for the confidentiality of the records released to me and that I may have to pay a reasonable fee to get a copy. Additionally, I understand that my records may be used for telehealth program evaluation, education, and research and that I will not be personally identified if such a use occurs. I hereby authorize these disclosures to take place without prior written consent.


I understand that I am not entitled to royalties or to other forms of compensation for participation in any telehealth consultation(s) or information exchange.


I have received a copy of my practitioner's contact information, including his/her name, telephone number, business address, mailing address, and email address (if applicable). I have also been provided with a list of local support services in case of an emergency. I am aware that my practitioner may contact the proper authorities and/or my designated local contact person in case of an emergency.


I acknowledge, however, that if I am facing or if I think I may be facing an emergency situation that could result in harm to me or to another person; I am not to seek a telehealth consultation. Instead I agree to seek care immediately through my own local health care practitioner or at the nearest hospital emergency department or by calling 911.


I unconditionally release and discharge Amy B. Faust, LPC and any other organization involved in the remote consultation(s) from any liability in connection with my participation with telehealth remote consultations.


I have read this document carefully and fully understand the benefits and risks. I have had the opportunity to ask questions I have and received satisfactory answers. With this knowledge, I voluntarily consent to participate in the telehealth video, phone or messaging consultation(s), including but not limited to any care, treatment, and services deemed necessary and advisable, under the terms described herein.


( Type Full Name )
( Full Name )
Privacy Act/HIPPA
I. PLEDGE REGARDING HEALTH INFORMATION (Privacy Act:


Amy B. Faust, LPC (henceforth referred to as "practitioner") understands that health information about you and your health care is personal. This practitioner is committed to protecting health information about you. A record of the care and services you receive from Amy B. Faust, LPC is maintained in a secured electronic environment. This record is required in order to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this mental health care practice. This notice will tell you about the ways in which your protected health information may be used and disclosed about you. Additionally, your rights to the health information kept about you will be described here, and certain obligations regarding the use and disclosure of your health information is described here as well. 


Amy B. Faust, LPC is required by law to:

- Make sure that protected health information ("PHI") that identifies you is kept private.

- Give you this notice of the practitioners duties and privacy practices with respect to health information.

- Follow the terms of the notice that is currently in effect.

- Amy B. Faust, LPC can change the terms of this Notice, and such changes will apply to all information recorded about you. The new Notice will be available upon request.


II. HOW AMY B. FAUST, LPC MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:


The following categories describe different ways that this practitioner may use and disclose health information. For each category of uses or disclosures you will receive an explanation regarding what is meant along with pertinent and examples. Not every use or disclosure in a category will be listed. However, all of the ways in which this provider is permitted to use and disclose information will fall within one of the categories.


For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client's personal health information without the client's written authorization, to carry out the health care provider's own treatment, payment or health care operations. This practitioner may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.


Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word "treatment" includes, among other things, the coordination and management of health care providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.


Lawsuits and Disputes: If you are involved in a lawsuit, your practitioner may disclose health information in response to a court or administrative order. She may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.


III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:


1. Psychotherapy Notes. Amy B. Faust, LPC does keep "psychotherapy notes" as that term is defined in 45 CFR 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For use in treating you.

b. For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For use in defending herself in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.


2. Marketing Purposes. As a psychotherapist, your PHI will not be used or disclosed for marketing purposes.


3. Sale of PHI. As a psychotherapist, your PHI will not be sold in the regular course of business.


IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, the use and disclosure or your PHI without your Authorization can be done for the following reasons:


1. When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2. For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone's health or safety.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although this practitioner's preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on business premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8. Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9. For workers' compensation purposes. Although again, this practitioners preference is to obtain an Authorization from you, she may provide your PHI in order to comply with workers' compensation laws.

10. Appointment reminders and health related benefits or services. This practitioner may use and disclose your PHI to contact you to remind you that you have a scheduled appointment. She may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that are offered.


V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.

1. Disclosures to family, friends, or others. Amy B. Faust, LPC may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations. This person is typically listed in your emergency contact record.


VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:


1. The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask this practitioner not to use or disclose certain PHI for treatment, payment, or health care operations purposes. Amy B. Faust, LPC is not required to agree to your request, and may say "no" if she   believes it would affect your health care.

2. The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3. The Right to Choose How Your PHI is Sent to You. You have the right to ask this practitioner to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and she will agree to all reasonable requests.

4. The Right to See and Get Copies of Your PHI. Other than "psychotherapy notes," you have the right to get an electronic or paper copy of your medical record and other information that this practitioner has about you. You will be provided with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request.  Please be advised that you may be charged a reasonable, cost based fee for doing so.

5. The Right to Get a List of the Disclosures This Practitioner Has Made. You have the right to request a list of instances in which Amy B. Faust, LPC has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided with an Authorization. She will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list given you will include disclosures made in the last six years unless you request a shorter time. Amy B. Faust, LPC will provide the list to you at no charge, but if you make more than one request in the same year, you may be charged a reasonable cost based fee for each additional request.

6. The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that the existing information be corrected or that the missing information will be added. Should this practitioner refuse your request, you will receive an explanation in writing within 60 days of receiving your request.

7. The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.


ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.

( Type Full Name )
( Full Name )
Cancellation Policy

We understand that on occasion a need may arise wherein a scheduled appointment may be cancelled.  Please keep in mind that your scheduled appointments are reserved, for you, and therefore that time is now blocked off in Amy's calendar.  As such, should you need to cancel your appointment, please contact our office at least 24 hours in advance to cancel the appointment.  


Appointments cancelled within the 24 hour time frame may result in a $25 cancellation fee.  A missed appointment without a prior cancellation notification (call, email or text) made within two hours of the scheduled time may result in a charge of the full appointment of the originally scheduled rate.  Because we recognize that there are occasions when a call is not feasible and an appointment may be missed, Amy can and may, at her discretion choose to waive this fee.  


Your signature indicates your agreement with this policy.

( Type Full Name )
( Full Name )
Session Payment Policy

Please be advised that Amy B. Faust, LPC does not bill directly to your insurance company.  All clients are responsible to pay for their sessions immediately upon completion of that session.  A completed invoice will be emailed, via the secured client portal, to each client upon payment of their sessions.  This invoice may be used for submittal to an insurance company.  


Monthly Messaging Plans are due each month on the anniversary of the agreed upon start date, for example: a plan that began on January 1st, will be billed and due again on February 1st, March 1st, and so on, until cancelled.  


Message Only Plans are billed and due immediately upon completion of each message.


Any and all follow up sessions may be cancelled should payment for a completed session not be received prior to the next scheduled session.




( Type Full Name )
( Full Name )