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Terms and Policy

Notice of Privacy Practices
Our notice of Privacy Practices, according to HIPPA (Health Information Portability and Accountability Act) provides information about how we may use and/or release protected health information about you. You have the right to review our notice before signing this form. As provided in our notice, the terms of our notice may change. If our notice changes, you may obtain a revised copy via a written request submitted to our office staff.

Our notice informs you that we will restrict how your protected health information is used or released for treatment, payment, or healthcare operations. We commit to use or disclose the minimum amount of your personal health information necessary to perform the following functions:

Disclosures may be made to the following:

-The military, if you are a member of the armed services
-Health care sponsors for payment or other claim purposes, such as coordination
of benefits
-Approved business associates, such as other healthcare providers for
coordination of medical care
-Other health care related benefits, and/or services that may be of interest to
you- such as public health agencies
-Law enforcement personnel in response to legal requirements
-Legal representative in response to a court order or other legal proceedings,
such as medical examiners, funeral directors, national security and other
intelligence agencies as authorized by federal or state law.

You have the right to request that we restrict how your protected health information is used or released for treatment, payment, or other healthcare operations. We are not required to agree to this restriction, however, if we do, we are bound by our agreement.

By signing this form, you consent to our use and release of your protected health information for treatment.
( Type Full Name )
According to Florida Title XXIX/394.459, patients have the rights to the following:

1. The right to individual dignity.

2. The right to treatment, which includes treatment regardless of the patient’s ability to pay for the services and treatment that addresses the problem in the least restrictive fashion.

3. The right to express and informed patient consent.

4. The quality of treatment, which includes providing treatment that is best suited for the patient, treatment procedures and documentation must be understandable to the patient.

5. The patient has the right to private communication outside the facility, which includes all mail and information regarding the procedure to report abuse.
( Type Full Name )
Appointment Cancellation
Policy Regarding Telephone Sessions

As noted in the Outpatient Services Informed Consent Contract, I am often difficult to reach by telephone, however if you leave me a message I will make every effort to return your call the same day you make it with the exception of weekends and holidays. Be advised that any telephone conversation lasting longer then 10 minutes will become a psychotherapy session and a fee of $200.00 will be incurred. Insurance will not pay for telephone sessions. Therefore, payment arrangements must be made in advance. In the case of a crisis call, your credit card will be charged or you will be sent a bill in the mail. I accept most major credit cards, cash, personal checks and money orders.

Policy Regarding Appointment Cancellation

Every effort is made to accommodate you with the appointment dates and times you request.
It is essential that you contact my office if you need to cancel an appointment so that session time can be offered to someone else on my waiting list. My cancellation policy is: no charge for appointments canceled 24 hours in advance. Cancellation the day of your appointment will result in a $50.00 fee, unless there is an emergency or illness. No call or no show for an appointment will result in a $200.00 fee. This amount must be paid out of pocket and cannot be billed to insurance.

I understand and agree to the stipulations set forth herein as to the Policy Regarding Telephone Sessions and the Policy Regarding Appointment Cancellations.
( Type Full Name )
Initial Consultation- Informed Consent
Before we begin, I am required to have your consent to start our initial consultation interview. The initial consultation includes a 45 - 60 minute discussion on the following: Florida's informed consent requirements, confidentiality, limitations to confidentiality, the disclosure requirements according to Health Information and Portability and Accountability Act (HIPPA), an explanation of my education, experience and practices, as per requested, and a brief assessment of your needs and difficulties.

By signing this consent form I certify that I have read this form and that the therapist has discussed the Florida's informed consent requirements, confidentiality, limitations to confidentiality, disclosure requirements according to Health Information and Portability and Accountability Act (HIPPA), an explanation of education, experience, and practices, and has conducted a brief assessment of my needs and difficulties. Furthermore, by signing this form I am consenting to begin the initial consultation and any additional counseling and treatment sessions that follow, until treatment is complete, or until the therapeutic relationship is concluded.

By signing this consent form I agree that I am financially responsible and liable to pay in full prior to each counseling session. I also agree that I am responsible to pay a NO SHOW/NO CALL FEE of $200.00 for any missed counseling sessions when the therapist is not notified by telephone at 407-704-3166 any less then 24 hours from the scheduled appointment time.
( Type Full Name )

1. I may at some time or have requested that my health care provider and I engage in a telehealth consultation.

2. My health care provider has explained to me how the video/telephone conferencing technology will be used to affect such a consultation and will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3. I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the video/telephone conferencing  connections are not adequate for the situation.

4. I have had the alternatives to a telehealth consultation explained to me and I'm choosing to participate in a telehealth consultation. 

5.In an emergent consultation, I understand that the responsibility of the telehealth practioner will advise my local practitioner and that the specialist's responsibility will conclude upon the termination of the video/telephone  conference connection.

6.I understand that if required by your insurance or EAP payee, the billing will occur from both my practitioner and as a facility fee from the site from which I am present.

7.I agree that I am responsible to pay my counselor for any telehealth consultations if my insurance or EAP provider refuses to cover my telehealth consultation appointments. 

8.I have had a direct conversation with my counselor, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.

By signing this form, I certify:

That I have read or had this form read and/or had this form explained to me

That I fully understand its contents including the risks and benefits of the procedure(s).

That I have been given ample opportunity to ask questions and that any questions have been answered to

my satisfaction.

( Type Full Name )