Professional Services and HIPAA Information

This document contains important information about my professional services and business policies. It also contains information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.

HIPAA requires that we provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information.

Professional Fees

Session fees may vary and will be disclosed to you prior to your consultation. I charge by the hour for other professional services you may need. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require my participation, additional professional fees may apply.

Contact and Communication Policy

Due to our varied work schedules and the improbability of my answering the phone when with a patient, I am often not immediately available by telephone. When I am unavailable, the telephone is answered by voice mail that is monitored frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends and holidays.

Agreement Terms

It is very important that you read the terms carefully. We can discuss any questions you have about the procedures at any time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.

ESA Evaluation Consent

I understand that I am requesting an evaluation for an Emotional Support Animal (ESA) letter. I acknowledge that:

• This evaluation will assess my mental health condition and need for emotional support
• The licensed mental health professional will review my responses and determine eligibility
• An ESA letter will only be provided if clinically appropriate
• I will provide accurate and complete information during this evaluation
• I understand the responsibilities that come with having an ESA
• I understand that additional fees may apply if circumstances arise requiring additional services

Minor Authorization

For services provided to minors: If you are seeking services for a minor, by signing this agreement, you are providing parental authorization for treatment and consent to the release of medical information as outlined in this agreement.

Electronic Signature Acknowledgment

By signing below, I acknowledge that I have read, understood, and agree to all terms outlined in this Patient Services Agreement, including HIPAA disclosures, professional fee policies, communication procedures, and consent for ESA evaluation services.