BASIC INFORMATION & CONTACT PREFERENCES
____________________________________________ _____ / ________________
Full Name and Preferred Name(s) Age Date of Birth
Street Address City, State, Zip Code
______________________________________ ___ Yes / ___ No
Preferred phone for communication May a message be left at this number?
May a text message with appointment information be sent to this number? ___ Yes / ___ No
(Consider who else may access/view text messages before agreeing to allow messages)
Do you wish to receive email about workshops/other offerings? ___ Yes / ___ No
Briefly state what you hope to address in therapy and/or what brings you to therapy:
Relationship/Parenting status/Caregiving roles:
Gender/Sexual or related identity:
Spirituality or Faith Identity and its importance to you:
Ethnic and Cultural Identity and its importance to you:
Other area of identity you wish to disclose:
Educational Status: share your educational level and/or participation:
Employment Information: share your occupation or other information about paid work:
Other information important to you or that you want me to know:
EMERGENCY CONTACT INFORMATION
By listing a person in this section, you confirm permission to contact this person in the event of an emergency. What constitutes an emergency will be discussed at your initial appointment.
Contact Name: Contact Relationship to You:
________________________________ ___ Yes / ___ No
Contact Telephone Number: Is phone number capable of receiving text messages?
Contact Street Address City, State, Zip Code
Please list any restrictions for Emergency Contact:
AGREEMENT FOR SERVICES
IF YOU CANNOT CHECK “YES” TO ANY SECTION BELOW, PLEASE CONTACT KATE TO DISCUSS AND RESOLVE BEFORE COMPLETING THIS FORM OR SIGNING THIS AGREEMENT.
Privacy Protection and Payment for Services: Mind Path Wellness uses Square for payment processing as this is a trusted, secure payment processing entity. By checking "yes,” you confirm you are aware that Mind Path Wellness uses a payment processor to collect payment and agree to “Mind Path Wellness Services” as the charge description on credit card and/or banking statements. This information may also appear on any social media or other Internet sites you have allowed to track your online actions, all of which are outside the control of Mind Path Wellness/Kate Robinson.
___ Yes / ___ No
Payment: please select whether you are an Open Path or sliding scale fee client. The fee may be adjusted at review for Open Path clients or at Kate's discretion with at least one month's notice of any increase or change.
___Open Path Collective negotiated rate (required registration with Open Path Collective)
___ Sliding Scale Fee
Please select one or more appointment reminder options: (note: Mind Path Wellness recognizes that unforeseen and emergency circumstances may occur and interfere with keeping an appointment. Because time is set aside that is otherwise unpaid for your therapist, there are cancellation policies related to fees paid. Mind Path Wellness offers the option of rescheduling a missed appointment one time before the fee is non-refundable. By selecting a reminder option, permission is granted to send a reminder text or leave a phone message that you have an appointment with Mind Path Wellness.
___ Please text 24 hours before my appointment. I will pay the fee at that time.
___ Please email 24 hours before my appointment. I will pay the fee at that time.
I am aware that Mind Path Wellness does not accept or process insurance claims. I am aware that this means that I am also not eligible for a "super bill" and will not allow anyone else to request or submit to an insurance company for reimbursement.
___ Yes / ___ No
I attest that I am not receiving Medicaid or Medicare Coverage. This means I cannot submit a bill to Medicaid or Medicare for consideration and I will not allow another person to submit a bill on my behalf.
___ Yes / ___ No
I agree that I am responsible for all charges and that I will pay the agreed upon fee 24 hours prior to a scheduled appointment so that the cancellation fee (the cost of the appointment) is paid in the event I cancel with less than a 24-hours-notice. If I do not pay the fee 24 hours prior to my scheduled appointment, I am aware that Mind Path Wellness is not obligated to hold the appointment time since nonpayment may be construed as notice of cancellation. I agree that I am responsible for contacting Kate Robinson to either reschedule or confirm my appointment and make an alternative payment arrangement that she determines. (Please see additional information at the Cancellation Policy section of this form set.)
___ Yes / ___ No
Rather than complete a separate signature page for each document, please check that you have received, understand, and/or have had all concerns addressed for each of the policies/notices/forms named below. This is a convenience offered to reduce paperwork required to be returned and to allow you to keep all policies/notices/forms for your reference and records.
__ Agreement for Services
__ Electronic communications policy
__ Cancellation policy
__ Social networking policy
__ Custody, court, and other legal issues policy
__ Privacy and Confidentiality
__ Client Rights
__ HIPAA Privacy Practices
__ No Surprises Act, Patients First Act, and Good Faith Estimate
By signing below, I attest that I received, understand, and agree to the forms, policies, and practices listed above and that I have had an opportunity to ask questions about any portion that I did not understand.
Client Signature Date
Printed Name _________________________________
POLICIES & DISCLOSURES
This section discusses Mind Path Wellness policies and requires a signature page be completed that is connected to the Agreement for Services. This allows you to keep the policies for your own reference and to return limited paperwork to me. Due to changing requirements by laws and statutes, these policies may be amended from time to time and if changes are made, you will be notified and requested to confirm receipt and agreement of any changes.
Electronic Communication (email, text, phone, tele-health) Kate Robinson/Mind Path Wellness takes seriously the ethical and legal obligation to engage in the most secure forms of communication to ensure that your privacy and protected health in-formation is not accessed by anyone not authorized to view this information. While every effort may be made, including securing Business Association Agreements and “HIPAA-compliant” means of storage of information or for communication, there remains a risk of information being accessed or otherwise obtained by unauthorized parties. By my signature and check mark on the signature page at “electronic communication policy,” I hereby agree to the following with regard to electronic communication:
1) I am aware that electronic forms of communication including text messaging, email, and phone communications including voice mail are subject to breaches of confidentiality that lie beyond the attempts at encryption or other methods of protection Mind Path Wellness and Kate Robinson may take to ensure confidentiality. I agree that if I choose to disclose or transmit information related to appointments or to my diagnoses or other protected health or financial information, I assume the risk of breach of security that is otherwise not preventable by known means already in place to increase security of transmission.
2) I am aware that Kate Robinson and Mind Path Wellness keeps specific business hours and that Kate Robinson is not available 24/7/365 in the event of emergency. In case of emergency, I am aware of local hospitals and emergency phone numbers or other means of securing care for physical and/or mental health emergencies. Kate Robinson does not provide triage or other crisis management services. Voicemail, email, and text communications are answered as quickly as possible within the hours of operation.
3) As a client, I am welcome to attempt to reach Kate Robinson via email at firstname.lastname@example.org or phone at 401-500-3535 and I am aware that personal health information disclosed at these locations through digital recording are as secure as possible yet may be subject to breaches that are not preventable. I am aware that information left by electronic means in any form is done so at my own risk.
4) I am aware that information may be stored in a cellphone, laptop, or by a service provider such as a cellular phone provider or internet service related to location, phone numbers, and other such identifying information and that this information may be subpoenaed by law enforcement personal or courts.
5) I am aware that Kate Robinson may take vacations or participate in trainings or other educational endeavors and may not be available for periods of time. If I am engaged in regular therapy with Kate, she will inform me in advance of periods of unavailability and plan with me accordingly for either coverage in her absence or ensure a plan is in place to manage a crisis. If a client reaches out after a period of not being in therapy regularly, Kate will leave an out of office email and voice message that will indicate when she returns and advice on who may be contacted in her absence.
Cancellation Policy: By my signature and check mark on the signature page at “cancellation policy,” I hereby agree to the following with regard to cancellation: When therapy begins, a treatment and frequency recommendation will be developed. Achieving desired change in therapy requires commitment of the therapist and client together. As a result, scheduled appointments should be treated as important and prioritized the way that other appointments for care are viewed. It is understood that there are times when a client will miss an appointment due to an unforeseen and extreme circumstance. Aside from a rare instance of an unforeseen issue or extreme circumstance, appointments are expected to be kept or cancelled with appropriate notice. The time scheduled for you often cannot be scheduled for another client. I understand that it is my responsibility to notify Kate Robinson that I will not attend my appointment as soon as possible when I am aware I will be late or miss the session. I will attempt to reach Kate Robinson via phone, email, and/or text message as the fastest means of communication. Having read the electronic communication policy above, I will leave only the basic information necessary and any other information shared is done so at my risk. Cancellation Fees: There is a fee charged for cancellations with less than 24 hours-notice equal to the cost of the session. Once a discussion takes place related to the reason for cancellation without 24 hours-notice, the fee collected may be applied to a future session at Kate’s discretion. This is not meant to be a punitive policy and exceptions are possible in extenuating circumstances. The purpose of this fee is to cover the fee earnings lost when an appointment spot cannot be filled. Because of the nature of shift work, Kate may establish an alternative policy or arrangement, please discuss with her and this agreement will be amended.
Social Networking: Mind Path Wellness and Kate Robinson maintain public Instagram and Facebook accounts. The Mind Path Wellness accounts are meant to provide information and share resources with anyone with similar interests. Please be aware that joining the Mind Path Wellness Instagram by “following” it or a Facebook Page, you may place yourself at risk of others becoming aware of your affiliation with a site/page/account that promotes mental health information. If you request a “follow back” I will not likely comply as I do not wish to breach confidentiality or create a situation where your shared content is problematic for any of my followers/friends/connections on social media. I am unable to accept “friend” requests on Facebook on my personal account due to a desire to respect individual privacy to which you have a right and to which I have a right. This is in the best interest of keeping the therapeutic relationship a special relationship with strong, healthy boundaries for both of our sakes. This ensures confidentiality and privacy and helps allow separation of my professional and personal life and your persona life from your mental health and wellness treatment. By my signature and check mark on the signature page at “social media policy,” I hereby agree to the foregoing social networking policy.
Custody, Court, and Other Legal Issues: Kate Robinson will not testify on behalf of a client in a court proceeding for custody or for civil or criminal or other court proceedings. In rare or specific circumstances, Kate Robinson may prepare a letter that confirms treatment dates or other basic information that may be used for a court matter. Any such letter will be addressed to you as a client and will contain the information you specifically request. Any release of such a letter to any other party is done so at your own risk and does not constitute Kate Robinson disclosing protected health, mental health treatment, or other protected health information since the information is released only to you for your own use. Requests for letters with specific information can only be written when the information requested is accurate according to Kate’s treatment record for you and you have made the request in writing. There may be a fee for such a letter, and you will determine any cost with Kate at the time of request.
Kate Robinson does not write work letters or complete disability forms for leave.
Kate Robinson does not complete court (forensic) evaluations or disability determinations.
Kate Robinson does not write pet/companion animal or service animal letters. Please refer to a medical provider for notes or documents related to loss of work or a need for a letter related to a pet or animal or for disability issues.
While you may miss work due to a mental health condition, a letter written by a therapist discloses engagement in therapy and may place you at increased risk with an employer. As a result, Kate Robinson refers you to your primary care medical provider for anything related to work.
My position of non-participation in court-related matters is that I believe this type of disclosure may run the risk of damaging our therapeutic rapport and violate our protected communication.
Notwithstanding this position, you are aware by this policy that I may be compelled by a court to present testimony or records and that I will comply with investigative agencies and personnel when there is a court order to do so as I am obligated under the law in this instance.
My policy would be to inform you of any request if I am able to be in touch with you to attempt to discuss ahead of time the nature of what I am being requested to release for your information purposes. If the safety of another person or of you would be jeopardized by such disclosure, I will respond to the court as ordered without communication.
If you wish forms for determination of mental illness, disability, court involvement with custody or assessments to be completed, I would be happy to refer you to practitioners in the area who offer this service. Should I be called to court by a judge court order, or our records are court ordered or subpoenaed, I will charge the full amount applicable under law for services. If you are working with an attorney who wishes to ask the court for an order that compels me to participate in court or other legal or legal-related proceedings (such as arbitration), a fee of $175/hour will apply to labor involved in preparing records, testimony, and for the time involved in appearing. Additionally, any fees related to travel or parking or expenses to attend trial or other court or legal-related proceedings will be reimbursed by you after I present a bill with attached receipts. Time spent in preparing documents or testimony or giving testimony is billed to the nearest quarter hour.
Privacy and Confidentiality: As a health provider, I have an obligation to protect your privacy and respect your right to confidentiality of information shared as part of intake, ongoing treatment, and the conclusion of treatment. Information share is considered PHI or Protected Health Information under local, state, and federal privacy laws including HIPAA or the Health Information Portability and Accountability Act.
Exceptions to Confidentiality: The State of Rhode Island and Commonwealth of Massachusetts have specific laws related to confidentiality and protected health information and have determined instances in which, as a healthcare provider, I am mandated to report and thereby disclose information that may have been shared in confidence and the privacy of therapy and these are as follows:
Abuse and neglect of a child, disabled, or elderly person must be reported if/when it is disclosed. Abuse and neglect include maltreatment of any kind, exploitation of any kind, physical abuse, emotional abuse, and/or sexual abuse. If a person’s life and safety are at risk, these are reportable for these protected populations.
For pregnant women, I am legally required to report use of controlled substances during the pregnancy.
If you disclose a threat, intent, and/or plan to harm another person or to cause property damage that would jeopardize life and safety, I am obligated to report this.
If you disclose a threat, intent, and/or plan to harm yourself, I am obligated to report this.
If you engage in behaviors at work that potentially endanger the people or animals you serve, I am obligated to report this information to regulatory and/or licensing boards.
Group Therapy: while there are policies for groups around confidentiality, Kate Robinson is not responsible for a breach of confidentiality by another member of the group.
Client Rights: You have a right to be informed of billing practices, charges, and fees prior to agreeing to engage in services and to be provided with a billing statement as requested.
You have a right to be aware of your diagnosis/diagnoses and information kept in your mental health medical record excepting psychotherapy notes.
You have a right to be informed of the course of treatment and treatment plan that is agreed up-on mutually.
You have a right to seek therapy that is free of discrimination on the basis of your ethnic, cultural, religious, sexual, or gender identity, relationship status, age, nationality, disability status, and other protected classes under law or other self-identified aspects of intersectionality and identity.
You have a right to know my training, education, and licensing status. You have a right to make a grievance or report to the licensing board and are aware that you do so without retaliation or interference.
You have the right to inspect and inform yourself about licensing requirements and about the policies and regulations that govern therapeutic treatment.
You have a right to be informed of and to refuse, without recourse, of any proposed research in which Kate Robinson may engage.
You have a right to request copies of your billing records and treatment records, excepting psychotherapy notes, for your own use and/or for transfer to another provider. Requests for information must be made with at least 72 hours-notice and will be fulfilled within 14 business days or less. A fee may be charged for copies for the time and resources used in making this information available to you in accordance with the law.
Specific Privacy Practices Related to HIPAA: This section describes the ways in which medical information about you may be used and/or disclosed and the ways in which you may access your health record information. Please read and review this information carefully.
Uses and Disclosures for Treatment, Payment and Health Care Operations: Kate Robinson may use or disclose your protected health information (PHI) for treatment, payment, and health care operation purposes with your consent, which you provide by signing the signature page and checking the section that refers to HIPAA Privacy Practices.
Definition of Terms:
“PHI” refers to information in your health care record that could identify you.
“Treatment, Payment and Health Care Operations” Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider such as your family physician or another psychologist.
“Payment” is when I obtain reimbursement for your healthcare. Since I do not bill insurance companies or offer Super Bills, payment should always be directly between you and Kate Robinson/Mind Path Wellness.
“Health Care Operations” are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business related matters, such as audits and administrative services, case management and care coordination.
“Use” applies only to activities within my office, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside my office, such as releasing, transferring, or providing access to information about you to other parties. I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information.
You may revoke all such authorizations (of PHI) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage and the law provides the insurer the right to contest the claim under the policy. I will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.
Uses and Disclosures with Neither Consent nor Authorization: I may disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If I have reasonable cause to believe a minor child is being harmed physically or emotionally or is at risk of harm from neglect, I am legally mandated to report this suspicion to Rhode Island Department of Children, Youth, and Families or Massachusetts Department of Children and Families.
Adults: Disabled and/or Elderly Persons: If I have reasonable cause to believe a person who is disabled or who is an elder (or both) is being harmed physically or emotionally or is at risk of harm from neglect, I am legally mandated to report this suspicion to the appropriate disabled persons’ protection commission and/or the Board(s) of Elder Affairs in Rhode Island or Massachusetts.
Court or other Legal Proceedings Including Workers Compensation: If you are involved with a court proceeding and a request is made or information about your diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release information without written authorization from you or your legally appointed representative unless compelled by court order. The privilege does not apply if you are being evaluated by a third party or where the evaluation is court ordered. You will be informed in advance whenever possible if I must make a disclosure based on a court order or if I receive an authorization from a third party rather than a direct request from you to release this information. I reserve the right to charge for the time and materials in preparing copies to be provided that are your responsibility.
If you file a workers compensation claim, and records are compelled, the information may become known or be shared with your employer by its attorneys and/or the Workers Compensation Board/Division. There are specific laws related to privacy in Massachusetts and Rhode Island and these will be followed to protect you with disclosure made only as required to an entity such as a medical examiner’s or coroner’s office, certain government agencies such as the military or Veteran’s Administration, or to public health offices as oversight agencies.
Duty to Warn: If you inform me that you plan to kill or seriously harm yourself or another person, who you identify specifically, I am mandated by law to warn a potential victim(s), notify law enforcement, and/or arrange for you to be hospitalized to protect yourself and/or identified others. This includes a suspicion that you are likely to act on threats based on prior history of violence.
Suicidality: If you present with the intent and/or a plan for suicide with potential for access to identified means, and you refuse to engage with recommended treatment, I may need to secure treatment for you by seeking your commitment to a treatment facility such as a psychiatric hospital. I may also contact your family or other individuals if they may be at risk (see duty to warn above) due to your stated means, intent, and/or plan for self-harm. You have a right to request restricted access to uses and disclosure of PHI about you. Kate Robinson is not legally obligated to honor your restriction and am obligated to refuse it based on the use and disclosure information listed herein this document.
You have a right to receive notices such as this and to receive information about your confidential record by alternative means and/or location. For example, you may use an email or mailing address that is not your home address or email. While I may honor this request, I am not responsible for breaches of confidentiality such as your supervisor becoming aware of your treatment if you receive a billing receipt at work rather than at home where household members may see it.
You have a right to review and to have copies of your record (billing and treatment). In special instances, I may deny this right and must disclose my reasoning and include the denial and my reasoning in your record. You also have a right to amend or request a correction of information if, upon your review, you determine it is not accurate or there is a mistake. The amendment or correction may remain in your file along with the original information.
You have a right to physical/paper copies of your record and billing even if you choose to receive an electronic copy for convenience or speed. There is a fee associated with gathering and preparing documents that will be disclosed at the time of the request. Any laws governing fees and the timely nature of providing records will be adhered to by Kate Robinson/Mind Path Wellness.
You have a right to be notified if there is a breach of your PHI or violation of HIPAA or Rhode Island or Massachusetts privacy laws. I am legally obligated to inform you of a breach and to report this to the specific governing bodies that protect patient rights in the event of a security breach.
You have a right to the policies and notice of same as outlined in this document.
You have a right to a copy of any revisions of this policy.
Definitions Related to Breaches of Privacy: A “breach” is defined as the acquisition, access, use or disclosure of PHI in violation of the HIPAA Privacy Rule. Examples of a breach include: stolen or improperly accessed PHI; PHI inadvertently sent to the wrong provider or PHI that is “unsecured” if it is not encrypted to government standards especially when stored or transmitted electronically.
A use or disclosure of PHI that violates the Privacy Rule is presumed to be a breach unless I determine there is a low probability PHI has been compromised. When I become aware of or suspect a breach, I will conduct a Risk Assessment. I will keep a written record of that Risk Assessment. A Risk Assessment considers the following four factors to determine if PHI has been compromised: 1) The nature and extent of PHI involved. 2) To whom the PHI may have been disclosed and whether the PHI was actually acquired or viewed. 4) The extent to which the risk to the PHI has been mitigated. If the Risk Assessment fails to demonstrate that there is a low probability that the PHI has been compromised, I will notify you that there has been a breach if the PHI was unsecured. Notification will be made without unreasonable delay and within 60 days after discovery. This notice will be made to you in plain language and will include a brief description of the breach; a description of types of unsecured PHI involved; the steps you should take to protect against potential harm; a brief description of the steps I have taken to investigate the incident, mitigate harm, and protect against further breaches as well as my contact information. For breaches affecting fewer than 500 patients, I will keep a log of those breaches during the year and provide notice to HHS of all breaches during the calendar year, within 60 days after that year ends. For breaches affecting 500 patients or more, I will notify HHS immediately and send notifications to major media outlets in the area for publication purposes. After any breach, particularly one that requires no-tice, I will reassess my privacy and security practices to determine what changes should be made to prevent the re-occurrence of such breaches.
You have a right to ask questions and/or make complaints about these policies and notices or if you have a question or complaint about access to records.
You have a right to file a complaint with me and/or with the U.S. Dept. of Health and Human Services.
You have a right to not suffer retaliation if a complaint is made. This notice and these policies are effective as of April 1, 2021 and were revised on January 16, 2022.
"NO SURPRISES ACT" - GOOD FAITH ESTIMATE
[PATIENTS FIRST ACT (MASSACHUSETTS)]
Congress passed a law called the “No Surprises Act” that requires all health care providers to offer a “Good Faith Estimate” related to costs of care. The law’s original intent seemed to be to protect people who need emergency medical care from “surprise” bills when care provided in connection with treatment in a facility that accepts their insurance yet subcontracts out some services so that the health care provider who treats the person then bills them as an out of network provider. This would also apply to surgical procedures where pathology or other related services may be contracted out to providers without the knowledge of the patient. This requires non-participating providers to charge the in-network rate to anyone who receives their care, additionally. It also requires an estimate be provided to ensure that the person is aware of potential total costs. Massachusetts passed a similar bill called the Patients First Act, which requires similar information and disclosures.
The best example is if a person needed emergency care after a vehicle accident and went to a local emergency room by ambulance, had an x-ray and lab tests, and was discharged from the ER. The person would get an ambulance bill, and the ambulance responding, which they did not choose, is not in network with their insurer, resulting in a “surprise” out of network charge, that may be higher than what their insurer allows for an ambulance transport. Then, they get a bill for emergency room treatment from the hospital. Additionally, they get a bill from a radiologist who does not work at the hospital yet who read the x-ray as a contractor for the hospital and a lab that is off-site to the hospital and processes the tests submitted. The radiologist and lab may be “out of network” and have higher costs than the insurance company allows.
The point of the “No Surprises Act” is to avoid the scenario described above. There are many details to work out as far as to whom and where it applies. Additionally, for ongoing treatment like psychotherapy, there is confusion about how a “Good Faith Estimate” is supplied since there are not typically a set number of sessions for issues and clients might decide to work on another area when they find resolution for the initial reasons for therapy. Additionally, providers do not diagnose a person prior to having a session with them.
That all said, this information is being provided to let you know that you have a right to request a “Good Faith Estimate.” For the most part, the estimate of costs is the per session fee times the number of times we will meet in a given treatment period.
Additionally, since I work on a sliding scale basis, my fees are less than what would be billed, and then negotiated to be paid to me by your insurance company outside any deductible. For example, the going rate for psychotherapy in Massachusetts and Rhode Island ranges from $125/hourly to upwards of $300/hourly. For the most part, therapists who charge these amounts do so because they bill these figures to insurance companies. Insurance companies have copayments and reimburse (typically) only a portion of what is billed. For example, you might have a copayment (outside of your deductible) of $25 for an office visit for therapy. You attend a session and pay $25. Your therapist submits a bill for $175 for the hour. The insurance company, with whom the therapist is contracted, has negotiated that they will pay the therapist a standard rate for an hour of psychotherapy, such as $131 (notice this is not the $175 billed). This means the insurance company takes the $131 allowed charge, deducts the $25 of your copayment, and sends a check to your therapist for $106.
Since my rates are less than contracted rates, which I would not be aware of and could not be aware of since insurance companies do not make these public, I cannot estimate the amount I would be paid by the insurance company to determine a rate that matches that of your insurance coverage. The reason that my fees are lower is due to me not spending time outside of session submitting billing, following up on payments, or redoing notes and treatment plans if they are rejected, which means that your care would not be covered regardless. Additionally, while diagnosis considerations inform our work together, I do not spend time in session or outside of session on diagnosis nor does that figure into whether our work together is something insurance would cover. As we have likely discussed when we decided to work together, insurers require a diagnosis, which means you have a clinically significant presentation of a psychiatric illness. For example, if you struggle with symptoms of depression yet can move through your days without significant interruption of life roles, then you are not eligible for a depression diagnosis, which means insurance would not cover your treatment. Some practitioners will assign an “adjustment disorder” diagnosis to clients to get insurance to pay for treatment that is otherwise “sub-clinical” (meaning does not meet clinical criteria for diagnosis). This “catch all” is actually its own diagnosis with its own criteria and is often used incorrectly. Another option therapists use is to present a “worst case scenario” to the insurer and assign a depression diagnosis, for example, so that visits are covered.
If you have questions about your treatment and its cost, especially without use of insurance, please reach out to me. I am happy to provide a cost estimate and/or discuss this new law to the extent I understand it at this time myself. More information continues to be shared in professional circles as well as a potential for a pause on it being implemented until further government guidelines are provided.
Rather than wait on guidance since the laws are effective as of 1/1/22, this is my good faith effort to inform you of this new law that very well may benefit you in other areas of health care, and to open a discussion about what makes the most sense for me to comply with creating a “Good Faith Estimate” for you if you wish to have this information.
A sample of the Good Faith Estimate Information & Disclosure follows and is taken from guidelines developed by mental health provider professional organizations in an effort to assist private practice therapists with compliance with the new law:
No Surprises Act & Patients First Act – Good Faith Estimate Information & Disclosure
You have the right to receive a “Good Faith Estimate” explaining how much your medical care will cost. Under the “No Surprises Act,” a new law, healthcare providers must give clients who do not have insurance or are not using insurance an estimate of the bill for medical items and services. This estimate should list the total expected cost of any non-emergency items or services. This includes costs like medical tests, prescription drugs, equipment, and hospital fees. The Good Faith Estimate must be provided in writing at least one (1) business day before your medical service or item. You may also request a Good Faith Estimate before you schedule a service. If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill. Make sure you save a copy or picture of your Good Faith Estimate. For questions about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
The Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service and is based on information known at the time the estimate was created. The Good Faith Estimate does not (and cannot) include unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
You may contact the provider to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider, you will have to pay the higher amount. (This fee and process is determined by law and not this provider.)
GOOD FAITH ESTIMATE SAMPLE
Date of Birth
Diagnosis(es) - a diagnosis must be listed. If you have a sub-clinical presentation, a "Z" code can be used. "Z" codes are not billable to insurance companies, typically.
Date of Good Faith Estimate
Provider Name : Mind Path Wellness/Kate Robinson Estimated Total Cost
Total Estimated Cost
The following is a detailed list of expected charges for psychotherapy scheduled for the date(s) of service (if scheduled). If services are reoccurring, the estimated costs are valid for 12 months from the date of the Good Faith Estimate.
Details of Services and Items for Provider named above:
Service/Item Location Diagnosis Code Service Code Quantity Expected Cost
PSYCHOTHERAPY TELEHEALTH TBD TBD 1 HOUR TBD
Total Expected Charges from Provider/Cost for all services and items: