You are here: HIPAA Consent for Services
Purpose of this Form: Welcome to our practice. This form, called a Consent for Services, contains important information about our professional services and business policies, such as billing terms and cancellation policy. We’ve tried to be thorough in discussing different questions and issues and have tried to use clear language instead of legal terms. Although this form is long and sometimes complex, it is very important that you read it carefully. We can discuss any questions you have about the procedures during the first meeting. When you sign this document, it also represents an agreement between us.
Psychological Services—What We Do
Health Psych Maine (“HPM”) provides psychological and behavioral treatment and evaluation. Treatment may include psychotherapy such as cognitive-behavioral therapy (CBT), stress management, assertiveness training, biofeedback, psychoeducation, and possible collaboration with your other healthcare providers. Evaluation may include an interview, assessments, and review of medical records. We are happy to provide further information about any of our treatments or procedures.
Benefits and Risks: Psychotherapy can have benefits and risks. People are often able to improve their mood, outlook, and functioning. Since therapy sometimes involves discussing or working with unpleasant aspects of your life, you may at times experience uncomfortable feelings.
Empirically Based Treatments: Generally, our practice specializes in focused treatments that have been found to be effective through clinical research. We practice in accordance with something called the “scientist-practitioner model” and utilize empirically supported or empirically validated treatments whenever possible. We will do our best to describe these treatments to you and encourage you to ask questions and learn as much about the treatments as you wish.
Cognitive-Behavioral Therapy (CBT) involves changing behaviors and thoughts in order to improve confidence, functioning, mood, and outlook. This may involve gradually confronting challenging situations or difficult thoughts, though this always occurs at your pace. In the treatment of anxiety disorders, this usually involves exposure and desensitization procedures, which means gradually placing oneself in feared situations, allowing the anxiety to be provoked and then generally staying with the situation until the brain desensitizes and the anxiety subsides. Again, this occurs at your pace.
Biofeedback: If your treatment includes biofeedback for muscle or other relaxation training, this might mean placing sensors to read muscle tension in various places such as the head, neck, and back. Biofeedback is not painful, but if the process is at all uncomfortable for you, it can be stopped or modified at your request. More information is available on request, through our web site, and by talking with your psychologist or clinician.
Active Participation: For this type of treatment to be successful, you will need to take an active role by doing homework and practicing relevant behaviors, skills, or exercises between sessions.
Determining Treatment Options: Our first 1-3 meetings will involve an evaluation of your needs. By the end of the evaluation, we will be able to offer you some impressions about a treatment plan that we might follow if you decide to continue with therapy; alternatively, we might discuss other referral options if we do not provide the type of services you desire or need. You should evaluate this information along with your own opinions of whether you feel comfortable working with the psychologist or clinician at this clinic. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the clinician you select. If you have questions about the procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another behavioral health professional for a second opinion.
If Treatment is not Helping: After the end of five or six meetings, if we feel that treatment is not helping, we may suggest other options, including referrals to another provider pausing and resuming therapy at a later time. As ethical practitioners, we avoid providing services that do not seem to be helping. Sometimes, a good treatment simply may not be appropriate for a person at a particular time in that person’s life.
Limited Crisis Coverage: Our practice does not have 24-hour crisis coverage. If you will need crisis services over the course of treatment, it is important that you discuss this point with your psychologist or clinician during the first meeting. We may recommend that you seek services at an agency that can offer more crisis coverage than our practice can provide.
Length and Frequency of Sessions: Psychotherapy sessions are typically 38-60 minutes long and usually occur on a weekly basis in the beginning of treatment, with frequency tapering as treatment progresses, depending on your clinical needs and insurance company or other financial limits. Evaluations typically consist of a 60-minute interview with a psychologist, and the completion of one or more assessments.
No Show and Cancellation: If you are unable to keep an appointment you will provide notice of your cancellation at least 24 hours prior to the start time of your scheduled appointment by calling 207-872-5800 option 1 or sending an email to . If you have canceled with less than 24 hours’ notice or do not show up to a scheduled appointment HPM will charge your card on file $100 in accordance with the Attendance and Cancellation Policy.
Final Session: We have found it to be very helpful to have a final session as opposed to simply stopping your appointments or fading away. By having a final session, you and your psychologist or clinician can review what has happened so far and what might be done in the future to help manage your situation. If you should decide to stop treatment early, we request that you please schedule one final session with your psychologist or clinician.
Professional Fees and Billing/Payment Issues
Rates: Our rates vary depending on the type of service – counseling, evaluation, biofeedback, forensic work, etc. In addition, we perform different types of evaluations for different purposes and the rates vary accordingly. Before you come in for an evaluation, our intake coordinator will work with you regarding rates and insurance reimbursement. In circumstances of unusual financial hardship, we may be willing to negotiate a payment plan or a fee adjustment (unless prohibited by your insurance company).
Payment is Due Before Session: Your portion of payment is due at time of service, paid before the session. Our intake coordinator will work with you to estimate what your financial responsibility will be. This varies with each insurance company or plan. Please understand that sometimes we can only make a best guess ahead of time and will not know the final amount until the service has been billed and processed by your insurance company.
Assignment of Benefits: By signing this Consent for Services form, you are providing consent for us to bill your health insurer carrier if that is how we have agreed to secure payment for service. When we bill the insurance company, payment for services is thereby directed to us; if the insurance company accidentally sends the check to you, it is your responsibility to turn the check over to us.
Managed Care: If your insurance company is a managed care company:
Legal Proceedings: If you request our involvement in legal proceedings that require our participation (e.g., a personal injury lawsuit), we charge $360 per hour for preparation, $180 per hour for travel, and $400 per hour for actual testimony or deposition time. For legal proceedings, we require payment of $1500 in advance against anticipated fees. There is a cancellation fee if your lawyer or you cancel the need for testimony with short notice (48 hours or less). We have more detailed information about legal fees that we can give to your lawyer or to you if this becomes necessary. If our fees and expenses are less than the $1500 advance payment, we will refund the balance promptly. If they are more than projected, we will revise the estimate and require payment before additional services are rendered.
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for behavioral health treatment. If we agree to bill your health insurance carrier for the services provided, you should be aware that your contract with your insurance company requires that you authorize us to provide information relevant to the services provided. We are required to provide a clinical diagnosis. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files. You understand and acknowledge that HPM does not have any control over what the insurance company does with your health information after it receives it. For example, in some cases, your health insurance may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it and in accordance with our Notice of Privacy Practices Policy. By signing this document, you consent that we can provide requested information to your carrier in order to process payment for services delivered to you.
Once we have all of the information about your insurance coverage, we will discuss what you might expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end your sessions. It is important to remember that you have the right to ask us not to tell your health insurance company about care you receive if you pay for the care in full out of pocket.
Contacting Your Psychologist Or Clinician
Our telephones are answered either by a receptionist or by voice mail. We will make every effort to return your call within one business day of receiving it, with the exception of holidays. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach your psychologist or clinician and feel that you can’t wait for a return call, please use one of the options below. If your psychologist or clinician will be unavailable for an extended time, they may provide you with the name of a colleague to contact, if you request it.
If you require immediate services and cannot reach us:
Social Media: The clinicians at HPM will NOT communicate with or contact any of their clients through social media platforms like Twitter and Facebook. In addition, if your clinician should discover that they have accidentally established an online relationship with you, they will cancel that online relationship. These types of casual social contacts can create significant security risks for you.
Your clinician may participate on various social networks, but not in their professional capacity. If you have an online presence, there is a possibility that you may encounter your clinician by accident. If that occurs, please discuss it with your clinician during your time together. Communications with clients online have a high potential to compromise the professional relationship and therefore it is requested that you do not contact your clinician in this way. If you do, your clinician will not respond and will terminate the online contact.
Professional Record Keeping And Confidentiality
We will protect and maintain the privacy and confidentiality of your Protected Health Information (PHI) arising from all services that you receive from us in accordance with applicable federal and state rules, as well as our Notice of Privacy Practices Policy. Please review our Notice of Privacy Practices Policy or contact HPM’s Practice Manager if you have any questions or concerns about how we maintain, share, disclose, or release your PHI to or from others.
It is our office policy to retain clients’ records, including PHI for seven years after the end of our therapy services to you, and in accordance with 45 C.F.R. §164.508(b)(6).
Sometimes people wonder if they could build a friendship with their psychologist or clinician during or after finishing therapy. In your best interest, and in following the American Psychological Association’s (APA’s) ethical standards, please understand that your behavioral health professional can only be your therapist and cannot have other roles in your life. Psychologists and other clinicians are ethically bound to avoid “dual relationships” whenever possible. Similarly, we cannot serve as a professional therapist to someone who is already a friend.
In a small town especially, your psychologist or clinician may see you in the community. In the interest of protecting your confidentiality, they will generally not initiate a greeting or conversation; if you initiate, your clinician will respond, but otherwise, they will not initiate contact in public. We hope you will understand that this behavior is not a personal reaction to you, but rather is intended to protect your confidentiality.
Internet Searches: In this digital age, you might choose to gather information about your clinician through an internet search. There is an incredible amount of information available about individuals on the internet, much of which may be known to that person and some of which may be inaccurate or unknown. If you encounter any information about your clinician, through internet searches or by any other means, please discuss this with your clinician during your time together so that the information or misinformation does not unnecessarily impact your treatment.