This text is to be read from your point of view as a client. There is some content overlap between this Informed Consent section and the Notice of Privacy Practices (NPP); this redundancy is required by law.
All treatment is voluntary and I have the right to a full explanation of the rationale for any therapeutic suggestions or strategies. In keeping with standard psychology practice, State College Psychological Services (SCPS) consults with licensed professionals when they have questions or concerns about the effectiveness of their approach and/or specific strategies for psychotherapy.
My confidentiality will be very strictly protected. In life threatening emergencies (such as intent to harm myself or others) and in circumstances where children or the elderly are suspected of, or are actually being physically or sexually abused, SCPS is required by law to notify relevant parties or authorities. In addition, if I am involved in a lawsuit where I bring up the question of my mental health, I will have automatically waived my right to confidentiality. Whenever possible, SCPS will discuss necessary actions with me first.
Consent to use and disclose my health information
When SCPS assesses, treats, or refers me, they are collecting what the law calls Protected Health Information (PHI). They may use this information to decide on what treatment is best for me and to provide treatment to me. They may need to disclose varying amounts of PHI to my insurance company to arrange reimbursement for my treatment, or for other healthcare business functions. By signing this form, I am agreeing with the contents of the NPP and allowing SCPS to use and disclose my information as specified in the NPP. In order for me to work with my psychologist at SCPS, I am required to sign this consent form. In the future, SCPS may change how they use and share my information and so may change their NPP. If they do change it, they will let me know, and I can request a copy in person, by calling my psychologist, or by writing SCPS at the above address.
If I am concerned about the use and disclosure of specific information, I have the right to ask my psychologist not to use or share some of the information for treatment, payment, or administrative purposes. I will have to provide a written explanation of these restrictions. Although SCPS will try to respect my wishes, they are not required to agree to the limitations, and will discuss this with me.
After I have signed the consent, I have the right to revoke it. I can revoke it in person, but I must also provide an accompanying written request that I no longer consent. SCPS will comply with my wishes about using or sharing my information from that time on. However, they may already have used or shared some of my information and cannot change that.
Third party/insurance payments & authorization to release information
I give permission to release to the person responsible for payment and/or to my insurance company the information necessary to process claims related to psychotherapy services rendered by SCPS. The information that will be provided may include the following items (of the client and/or the insured): name, address, DOB, insurance ID #, SS #, insurance group #, fee, dates of services, type and location of service, diagnosis, and any other insurance information as specified by my insurance company.
Some insurance companies require periodic progress reports in order to secure additional ongoing sessions. If required, I understand that these reports may include the above information, plus a clinical summary of my treatment goals, progress, and justification of the need for additional services. My psychologist will let me know if my insurance company requests a progress report. This information will be incorporated into the insurance companies’ files, and in all probability, some of the information will be logged into a computer network. SCPS has no control over the insurance company’s use of this information and I may want to learn about my insurance company’s policies regarding this. It is important to remember that I always have the right to directly pay for services at SCPS without the use of insurance to avoid these complexities and issues of confidentiality.
Assignment of benefits
I hereby assign medical benefits, including those from government-sponsored programs (e.g., Medicare and Medicaid) and other health plans, to be paid to SCPS. I authorize any holder of my medical record information to release information to the appropriate entity and it agents in order to determine these benefits payable for related services. A photocopy of this assignment is to be considered as good as the original.
Guarantee of payment
Unless otherwise agreed upon in writing, the fee for an Initial Consultation (aka Psychological Evaluation) is $175; each following session is $150. I may cancel or reschedule any of my appointments by leaving a voice-mail with my psychologist. However:
If I do not provider 24-hour advance notice, I understand that I may be charged a late cancellation fee of 50% of the scheduled appointment (e.g., the late cancellation fee for a standard weekly session would be $75)
If I miss an appointment without any advanced notice, I will be responsible for the full session fee.
There is a return check fee of $40.
I will make all reasonable efforts to pay my fees in a timely fashion. Insurance companies still sometimes use USPS to mail statements of services/sessions rendered, the session dates, the amount that the insurance reimbursed, and the amount that I am responsible for paying to State College Psychological Services (SCPS) in the form of a possible deductible and/or co-pay and/or co-insurance.
As insurance companies increasingly go paperless, I may need to access my account through my insurance company’s website to read my Explanation of Benefits (EOB) and the breakdown of amounts paid for each session. If I have any questions, I can discuss this paperwork or electronic statements with my psychologist and they will answer to the best of their ability. I understand that, on occasion, I may need to directly contact my insurance company to clarify issues.
SCPS usually does insurance billing at the end of each month. I, as the payment guarantor, will be expected to pay SCPS the amount for which I am responsible for the sessions of that month, unless other arrangements have been made, such as billing a third party (e.g., parents). Again, I may be required to directly pay SCPS a deductible amount to SCPS before my insurance begins payment. I can and should check with my insurance regarding coverage for mental health services. All fees are ultimately the responsibility of me as a client. In the case of billing a third party, this person is the guarantor, and I will write their contact information on this document. A specific Authorization for Release of Information form will also be signed by me so that SCPS can bill the guarantor.
Some insurance companies will not reimburse for two appointments of a similar nature that are scheduled on the same day. If I choose to schedule an appointment with my physician or psychiatrist on the same day that I meet with my SCPS psychologist, my insurance might not pay for one of the appointments, and I would be responsible for paying the full fee. If this situation arises, I can reschedule one of the appointments, and I can talk with my SCPS psychologist about rescheduling for a different time that week if I would like. I can also consult with my insurance company directly to see if this issue applies to my particular coverage.
By signing below, I agree to pay all applicable charges, as well as those which are not paid in full by my insurance. SCPS would like to help ensure that I am not surprised by any fees, and an on-going discussion with my psychologist about financial issues is welcome.
If amounts due are not paid in a timely manner according to this financial policy, my account will be deemed delinquent and may be assigned to a collections agency. I agree to provide all of the information required by SCPS and my insurance company for billing purposes. If this information is not provided on a timely basis, SCPS has the right to pursue termination of treatment.
If I anticipate any changes in my insurance mental health coverage or if I change insurance companies, I will let SCPS know immediately so that we can discuss the impact of these changes. Services may not be covered as they had been with the prior insurance or may not be covered at all (i.e., your specific psychologist within SCPS may not be a “preferred provider” of the new insurance company). This is very important because I am responsible for any and all fees not covered by insurance.
Psychologist’s incapacity or death
I acknowledge that, in the event of my psychologist’s incapacity or death, it will become necessary for another licensed mental health professional to take possession of my file and records. By signing this information and consent form, I give my consent to allow another licensed mental health professional selected by my psychologist to take possession of my file and records. My records can also be submitted to my practitioner of choice by the practitioner that my psychologist has selected.
E-mail and texting policy (non-secure communications)
During the course of therapy, it often is useful to communicate by email and/or text message. These methods, in their typical form, are not confidential means of communication. If I use these methods to communicate with my psychologist, there is a reasonable chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:
· People in my home or other environments who can access my phone, computer, or other devices.
· My employer, if I use my work email to communicate with my psychologist.
· Third parties on the Internet, e.g. server administrators and others who monitor Internet traffic.
At present, SCPS does not utilize any secure, encrypted electronic communication; I will be informed if this changes. Electronic communication should only be used to (re)schedule appointments, to briefly address administrative matters, or to receive/exchange on-line materials, resources and recommendations of therapeutic value. For instance, there are times in which my SCPS psychologist may e-mail me with specific instructions or Internet resources regarding mindfulness, meditation, stress reduction, time management, etc. E-mails to me may recommend websites, podcasts, video-casts, mp3’s, or SCPS may attach to the e-mail readings of interest. Very occasionally, brief e-mails/texts may be exchanged in-between sessions to address a specific therapeutic issue or concern.
My psychologist includes a confidentiality notice in their e-mail signature, but this does not insure confidentiality. Due to space and capability issues of texting, my psychologist does not use a signature in texts. To increase privacy with both e-mail and texting, I can delete messages from SCPS as I see fit. At present, SCPS does not use any other forms of electronic communication such as Facebook Messenger or Twitter. These methods have very poor security. As part of standard practice, all electronic correspondence becomes part of my official record.
There are times that my psychologist does not check e-mail on a regular basis, so I understand that e-mail is not the appropriate form of communication in case of a crisis or for the last-minute cancellation of an appointment. I can leave a voice-mail or text my psychologist for these matters. I can also opt-out of communicating by e-mail or text.
Regular and emergency contact
My psychologist is available by cell-phone and has a confidential voice-mail. If I am in a crisis and need to contact my psychologist in a timely manner, I can follow this two-stage process: 1) leave a voice-mail, briefly describing the nature of my crisis and the number at which I can be reached; 2) send a text with my name, phone number, and the phrase “Emergency, please call”. My psychologist will respond as soon as possible. SCPS requests that I follow through with both methods due to the occasional unreliable nature of cell-phone technology (e.g., a phone being, usually for a short time, out of signal range). It seems that texts often transmit better than calls when there is a weaker signal. But, even texts can be delayed within the electronic system. I will also keep in mind that my psychologist is in therapy sessions and meetings throughout the day and evening, and may not immediately see my text.
Because SCPS wants to attend to my crisis and ensure my safety as quickly as possible, I can also immediately call the numbers below. These are 24/7 crisis land-lines which are staffed by mental health professionals. If I speak to one of these people, they will most likely subsequently be in touch with SCPS to coordinate care.
Again, if I need to speak to someone immediately, I should call:
Centre County crisis line (24 hours/day): 1-800-643-5432
The Meadows Psychiatric Center: 1-800-641-7529
In dangerous or immediately life-threatening situations, I will not hesitate to contact the police at 911.
Consent for treatment
By signing below, I acknowledge that I have read and understood the entirety of this document and agree to abide by its terms during my professional relationship with SCPS. This document is available on SCPS website in both digital and downloadable forms, and I can request a hard copy of this document from my psychologist.
Use the link below to open the above Informed Consent as a Word document.