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Terms and Policy

Telepsychology Services (eTherapy) Consent Form
Definition of Services:

Telepsychology (hereto "eTherapy") is the delivery of psychological services using interactive audio or audiovisual electronic systems (such as telephone, e-mail, chat and videoconferencing) where the Psychologist and the patient (client, hereto “patient”) are not in the same physical location.

The interactive electronic systems used by SHPS PLLC for eTherapy include network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols are used to safeguard data and protect against intentional or unintentional corruption. Every attempt is made (but no guarantees are conferred) to ensure compliance with HIPAA/HITECH acts, the federal medical privacy laws.

Due to the nature of the technology used, eTherapy may be experienced differently than “in person” treatment sessions. eTherapy involves arranging an appointment time wherein the patient uses his/her own computer (or another portable electronic device, e.g., an iPad or Smart Phone), and the Psychologist interfaces from her computer via a secure internet connection at a different (“remote”) location.

Telepsychology (eTherapy) Service Provider and Efforts at Quality and Security:

Suffolk Health Psychology Services, PLLC has selected Counsol.com and VSee to provide eTherapy. These platforms have attested to strong adherence to privacy and confidentiality standards, including HIPAA/HITECH compliance. Please feel free to ask further questions (or visit their respective websites) if you have any questions or concerns.

Risks and Benefits unique to eTherapy:

Potential benefits to eTherapy may include:
• Increased accessibility to psychological services
• Increased convenience
• Reduced costs for both the patient and practitioner
• The ability to reach (serve) individuals who might not otherwise have access to treatment
• Demonstrated overall empirical (scientific) support for outcomes similar to traditional psychotherapies
• That patients have reported positive experiences with videoconferencing

However there are also potential disadvantages (risks) to eTherapy, including:
• The knowledge that even the best security protocols can fail, causing a potential breach of privacy of patient confidential information
• Potential service interruptions during the eTherapy session
• Traditional face-to-face meetings are the best alternative to the use of eTherapy and are preferred whenever possible.

My requirements and Rights as a patient:

I, the patient, understand that I must be a resident of New York State, and the majority of eTherapy sessions need to be conducted in while I am physically located in New York State. I understand that I can verify the Dr. Dixon’s professional license (at http://www.op.nysed.gov/opsearches.htm), and I agree to accurately represent my identity and my physical location during eTherapy sessions.

I understand that I may be able to receive a limited number of eTherapy sessions while vacationing or visiting a state outside of New York State (subject to state regulations). I understand that I must provide Dr. Dixon with at least 2 weeks notice if I wish to receive eTherapy while visiting or vacationing outside of New York State.

I understand that I need a computer with Internet access and webcam ability to receive eTherapy. I understand that I also need access to a regular phone in the same room in case we experience a dropped videoconferencing connection.

I understand that proceeding with eTherapy is decided on an individual basis.

I understand that I am not eligible for eTherapy if I am actively at risk of harm to self or others. I understand that I will become ineligible for eTherapy if I become actively at risk of harm to self or others in the future. I agree to seek immediate care via the nearest emergency room if I become actively at risk of harm to self or others. If this is the case, or becomes the case in future, I understand that Dr. Dixon will recommend more appropriate alternatives to eTherapy (e.g., in-person) services.

I agree not to record any eTherapy sessions without written consent from Dr. Dixon. I understand that Dr. Dixon will not record any of our eTherapy sessions without my written consent. I will inform Dr. Dixon if any other person can hear or see any part of our session before and/or during the session. I understand that Dr. Dixon will inform me if any other person can hear or see any part of our session before and/or during the session. I understand that I, not Dr. Dixon, am responsible for the configuration of any electronic equipment used on my computer (or other electronic device) that is used for eTherapy. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.

Patient Consent To The Use of Telepsychology (eTherapy):

I have read and understand the information provided above regarding eTherapy. I have discussed it with Dr. Dixon and all of my questions have been answered to my satisfaction. I understand that my consent to eTherapy supplements but does not supersede my signed Consent To Treatment. I hereby give my informed consent for the use of eTherapy in my care.
( Type Full Name )
What You Should Know about Confidentiality in Therapy
I will treat what you tell me with great care. My professional ethics (that is, my profession’s rules about values and moral matters) and the laws of this state prevent me from telling anyone else what you tell me unless you give me written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the “confidentiality” of therapy. But I cannot promise that everything you tell me will never be revealed to someone else. There are some times when the law requires me to tell things to others. There are also some other limits on our confidentiality. We need to discuss these, because I want you to understand clearly what I can and cannot keep confidential. You need to know about these rules now, so that you don’t tell me something as a “secret” that I cannot keep secret. So please read these pages carefully, then please print and have this form ready for our first appointment, so that we can discuss any questions you might have, if you so choose, prior to continuing with treatment.

1. When you or other persons are in physical danger, the law requires me to tell others about it. Specifically:
a. If I come to believe that you are threatening serious harm to another person, I am required to try to protect that person. I may have to tell the person and the police, or perhaps try to have you put in a hospital.
b. If you seriously threaten or act in a way that is very likely to harm yourself, I may have to seek hospitalization for you, and/or to call on your family members or others who can help protect you. If such a situation does come up, I will fully discuss the situation with you before I do anything, unless there is a very strong reason not to.
c. In an emergency where your life or health is in danger, and I cannot get your consent, I may give another professional some information to protect your life. I will try to get your permission first, and I will discuss this with you as soon as possible afterwards.
d. If I believe or suspect that you are abusing a child, an elderly person, or a disabled person, I must file a report with a state agency. To “abuse” means to neglect, hurt, or sexually molest another person. I do not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. If this might be your situation, we should discuss the legal aspects in detail before you tell me anything about these topics. You may also want to talk to your lawyer.

In any of these situations, I would reveal only the information that is needed to protect you or the other person. I would not tell everything you have told me.

2. In general, if you become involved in a court case or proceeding, you can prevent me from testifying in court about what you have told me. This is called “privilege,” and it is your choice to prevent me from testifying or to allow me to do so. However, there are some situations where a judge or court may require me to testify:
a. In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt.
b. In cases where your emotional or mental condition is important information for a court’s decision.
c. During a malpractice case or an investigation of me or another therapist by a professional group.
d. In a civil commitment hearing to decide if you will be admitted to or continued in a psychiatric hospital.
e. When you are seeing me for court-ordered evaluations or treatment. In this case we need to discuss confidentiality fully, because you don’t have to tell me what you don’t want the court to find out through my report.
f. If you were sent to me for an evaluation by worker’s compensation or Social Security disability, I will be sending my report to a representative of that agency and it can contain anything that you tell me.

3. There are a few other things you must know about confidentiality and your treatment:
a. I may sometimes consult (talk) with another professional about your treatment. This other person is also required by professional ethics to keep your information confidential. Likewise, when I am out of town or unavailable, another therapist will be available to help my clients. I must give him or her some information about my clients, like you.
b. I am required to keep records of your treatment, such as the notes I take when we meet. You have a right to review these records. If something in the record might seriously upset you, I may not leave it out, but I will fully explain my reasons to you.

4. Here is what you need to know about confidentiality in regard to insurance and money matters:
a. If you use your health insurance to pay part of my fees, the insurance company, the managed care organization, or perhaps your employer’s benefits office may require me to provide information about your functioning in many areas of your life, your social and psychological history, and your current symptoms. I may also be required to provide a treatment plan for your problems and information on how you are doing in therapy.
b. I can give you a SuperBill so that you may send these to your insurance company to file a claim for reimbursement of services rendered, according to your benefits. That way, you can see what the company may know about our therapy. It is against the law for insurers to release information about our office visits to anyone without your written permission. Although I believe the insurance company will act morally and legally, I cannot control who sees this information after it leaves my office. You cannot be required to release more information just to get payments.
c. If you have been sent to me by your employer’s employee assistance program, the program’s staffers may require some information. Again, I believe that they will act morally and legally, but I cannot control who sees this information at their offices. If this is your situation, let us fully discuss my agreement with your employer or the program before we talk further.
d. If your account with me is unpaid and we have not arranged a payment plan, I can use legal means to get paid. The only information I will give to the court, a collection agency, or a lawyer will be your name and address, the dates we met for professional services, and the amount due to me.

5. Children and families create some special confidentiality questions.
a. When I treat children under the age of about 12, I must tell their parents or guardians whatever they ask me. As children grow more able to understand and choose, they assume legal rights. For those between the ages of 12 and 18, most of the details in things they tell me will be treated as confidential. However, parents or guardians do have the right to general information, including how therapy is going. They need to be able to make well-informed decisions about therapy. I may also have to tell parents or guardians some information about other family members that I am told, especially if these others’ actions put them or others in any danger.
b. In cases where I treat several members of a family (parents and children or other relatives), the confidentiality situation can become very complicated. I may have different duties toward different family members. At the start of our treatment, we must all have a clear understanding of our purposes and my role. Then we can be clear about any limits on confidentiality that may exist.
c. If you tell me something your spouse does not know, and not knowing this could harm him or her, I cannot promise to keep it confidential. I will work with you to decide on the best long-term way to handle situations like this.
d. If you and your spouse have a custody dispute I will need to know about it. My professional ethics prevent me from doing both therapy and custody evaluations.
e. If you are seeing me for marriage counseling, you must agree at the start of treatment that if you eventually decide to divorce, you will not request my testimony for either side. The court, however, may order me to testify.
f. At the start of family treatment, we must also specify which members of the family must sign a release form for the common record I create in the therapy or therapies. (See point 7b, below.)

6. Confidentiality in group therapy is also a special situation. In group therapy, the other members of the group are not therapists. They do not have the same ethics and laws that I have to work under. You cannot be certain that they will always keep what you say in the group confidential.

7. Finally, here are a few other points:
a. I will not record our therapy sessions on audiotape or videotape without your written permission.
b. If you want me to send information about our therapy to someone else, you must sign a “release-of-records” form. The practice website has a copy of this form, so you will know what is involved.
c. Any information that you tell me, and also share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court.

The laws and rules on confidentiality are complicated. Please bear in mind that I am not able to give you legal advice. If you have special or unusual concerns, and so need special advice, I strongly suggest that you talk to a lawyer to protect your interests legally and to act in your best interests.

The signatures to this form shows that we each have read, discussed, understand, and agree to abide by the points presented above.
( Type Full Name )
Consent to Use and Disclose Your Health Information (HIPAA)
This form is an agreement between you, and me (Denise Dixon, PhD, of Suffolk Health Psychology Services, PLLC). When we use the words “you” and “your” below, this can mean you, your child, a relative, or some other person if you have written his or her name here: .

When I examine, test, diagnose, treat, or refer you, I will be collecting what the law calls “protected health information”
(PHI) about you. I need to use this information to decide what treatment is best for you and to provide treatment to you. I may also share this information with others to arrange payment for your treatment, to help carry out certain business or government functions, or to help provide other treatment to you. By signing this form, you also agree to let me use your PHI and to send it to others for the purposes described above. Your signature acknowledges that you have read or heard the practice’s notice of privacy practices, which explains in more detail what your rights are and how I can use and share your information.

If you do not sign this form agreeing to the practice’s privacy practices, I cannot treat you. In the future, I may change how I use and share your information, and so I may change the notice of privacy practices. If I do change it, you can get a copy from the practice website, www.suffolkhealthpsych.com, or by emailing the practice at: privacy@suffolkhealthpsych.com.

If you are concerned about your PHI, you have the right to ask me not to use or share some of it for treatment, payment,
or administrative purposes. You will have to tell me what you want in writing. Although I will try to respect your wishes, I am not required to accept these limitations. However, if I do agree, I promise to do as you asked. After you have signed this consent, you have the right to revoke it by writing to me, as the privacy officer. I will then stop using or sharing your PHI, but I may already have used or shared some of it, and I cannot change that.
( Type Full Name )
Financial Policy
Suffolk Health Psychology Services, PLLC, (hereto referred to as "the practice") is committed to providing caring and professional behavioral health care to all clients/patients. In compliance with national standards of ethics, the practice is required to disclose all billing and financial matters regarding psychological (behavioral health) services. The practice is further required to have financial matters reviewed on a regular basis. As a client (patient) of the practice, you understand:

1. The usual and customary rate for provided psychological (behavioral health, including eTherapy) services are: $250 per 50 to 55 minutes for a New Patient Visit (to increase to $350, effective October 1, 2017); $200 for a 53-60 minute Follow Up Visit (FUV) (to increase to $300, effective October 1, 2017); $150 for a 38-45 minute FUV (to increase to $225, effective October 1, 2017); $100 for a 16-30 minute FUV (to increase to $150, effective October 1, 2017); and $50 for a 12-15 minute FUV (to increase to $75, effective October 1, 2017). Additional services are further detailed in the Payment Contract for Services.
2. The Person Responsible for Payment of Account (as noted in the Payment Contract for Services) is required to sign the form, Payment Contract for Services, which details fees for clinical and non-clinical services, and collection policies of the practice. The Person Responsible for Payment will be financially responsible for payment of all clinical and non-clinical services and fees. All payments are due *prior* to the practice rendering any services.
3. A credit/charge card is required to reserve all appointments, and the Person Responsible for Payment of Account is required to provide a valid credit card to allow the practice to automatically submit charges for any received services; any missed sessions; any late cancellations or rescheduled appointments (with less than 24 hours notice); and a flat fee of $15 per month for non-valid payments (including charge-backs on credit cards).
4. The parent or guardian of a minor is responsible for payments for the child at the time of service. Unaccompanied minors will be denied non-emergency service unless charges have been pre-authorized to an approved charge card or payment at the time of service.
5. When you schedule an appointment, that time belongs to you, and only you. Unlike traditional outpatient medical practices, this practice does not "double-" or "triple-book" appointments. As a result, missed appointments or cancellations/reschedules with less than 24 hours notice will be charged the full fee for the missed appointment (as a "late cancellation/no-show fee") regardless of the reason for the late cancellation or missed appointment.
6. The only exception to the late cancellation/reschedule policy regards an acute illness or injury in the patient (client) or child of the patient (client) that necessitates urgent or emergent medical attention. The late cancel/reschedule fee may be waived by the provision of documentation by a licensed health provider within 24 hours, or refunded by the provision of said documentation within 7 days of the cancelled/rescheduled appointment. No refunds will be provided after 7 days have passed.
7. If you elect to use out-of-network insurance coverage, you will have access to your statements ("Super Bills" or "Flex Bills") that you can submit to your insurance company. If you are permitted by your plan to work with someone out of your network, you will receive reimbursement according to your plan's provisions. However payment is due in full prior to each session while you await reimbursement.
8. In some cases insurance companies or other third-party payers may consider certain services as not reasonable or necessary or may determine that services are not covered (or reimbursable). In such cases the Person Responsible for Payment of Account is still responsible for payment of these services. Patients (clients) are charged the usual and customary rates for the area. Patients (clients) are responsible for payments regardless of any insurance company's arbitrary determination of usual and customary rates.
9. Payment methods include the following charge cards: Visa, MasterCard, American Express, and Discover. Clients (patients) using credit/charge cards must provide a valid credit card to remain on file so that charges may be submitted automatically by the practice. Alternatively, patients may pay for sessions in advance using a credit card or by submitting a payment via PayPal via the secure patient portal.

Please discuss any questions or concerns you may have regarding the financial policies with Dr Dixon.

I (we) have read, understand, and agree with the provisions of the Financial Policy.
( Type Full Name )
Notice of Privacy Practices (Brief Version)
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Commitment to your privacy
Suffolk Health Psychology Services, PLLC (SHPC, PLLC) is dedicated to maintaining the privacy of your personal health information as part of providing professional care. The practice is also required by law to keep your information private. These laws are complicated, but the practice must give you this important information. This is a shorter version of the attached, full, legally required notice of privacy practices. Please talk to Denise Dixon, PhD, as the privacy officer (see the end of this form) about any questions or problems.

How Suffolk Health Psychology Services, PLLC, uses and discloses your protected health information (PHI) with your consent:

Suffolk Health Psychology Services, PLLC, will use the information collected about you mainly to provide you with treatment, to arrange payment for services, and for some other business activities that are called, in the law, health care operations. After you have read this notice, you will be asked to e-sign a consent form to let the practice use and share your information in these ways. If you do not consent and sign this form, the practice cannot treat you. If the practice wants to use or send, share, or release your information for other purposes, it will be discussed with you, and you will be asked to sign an authorization form to allow this.

Disclosing your health information without your consent:

There are some times when the laws require the practice to use or share your information. For example:
1. When there is a serious threat to your or another’s health and safety or to the public. The practice will only share information with persons who are able to help prevent or reduce the threat.
2. When the practice is required to do so by lawsuits and other legal or court proceedings.
3. If a law enforcement official requires the practice to do so.
4. For workers’ compensation and similar benefit programs.
There are some other rare situations. They are described in the longer version of the notice of privacy practices.

Your rights regarding your health information
1. You can ask the practice to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask the practice to call you at home, and not at work, to schedule or cancel an appointment. The practice will try it’s best to do as you ask.
2. You can ask the practice to limit what it tells people involved in your care or the payment for your care, such as family members and friends.
3. You have the right to look at the health information the practice has about you, such as your medical and billing records. You can get a copy of these records, but the practice may charge you for it. Contact the privacy officer to arrange how to see your records. See below.
4. If you believe that the information in your records is incorrect or missing something important, you can ask the practice to make additions to your records to correct the situation. You have to make this request in writing and send it to the privacy officer. You must also tell the practice the reasons you want to make the changes.
5. You have the right to a copy of this notice. If we change this notice, the practice will post the new version on the website, and you can always get a copy of it from the privacy officer.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with the privacy officer and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care the practice provides to you in any way. Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. The practice will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or our health information privacy policies, please contact Denise Dixon, PhD, the practice owner and privacy officer, who is and can be reached by phone at or by e-mail the website at: www.suffolkhealthpsych.com.
( Type Full Name )