CLIENT INFORMATION

Welcome to Positive Connections Plus, LLC.  We will be continually working to provide you with appropriate, high-quality services.  We believe that a client who understands and participates in his/her care can achieve better results.  We have the responsibility to give you the best care possible, to respect your rights, and to recognize your responsibilities as a client.  We have prepared this information handout to help you identify these rights and responsibilities.

YOUR RIGHTS AS A CLIENT

Your Right to Privacy and Confidentiality: We follow the privacy provisions of state and federal laws and rules. You have the right to know the policies, practices, and limitations of the privacy of the information that you will share with us.

Your treatment record will be stored in a locked cabinet or computer which is protected from unauthorized access.  It is accessible only to personnel whom we have authorized to help us provide treatment to you.  Your treatment record includes your diagnosis, treatment plan, progress notes, psychological test report, psychiatric and other medical reports, and closing summary. Your billing record will be stored separately in a locked cabinet or computer protected from unauthorized access. It is accessible only to our billing office staff whom we have authorized to perform billing services. If you request that your insurance company pay for these services, we will share only the minimum information necessary for your insurance company to process claims.  We provide the following billing information to our billing staff for submission of claims to your insurance company; a) name and address of your insurance company; b) your subscriber and group plan numbers; c) your name, birth date, social security number, diagnosis, dates of service, type of service.  If your insurance company requires further information in order to process your claim (such as date of onset of your problems, history of your problems, symptoms that meet criteria for your diagnosis, your progress in treatment to date, and your goals and objectives for treatment), we will first consult you about your insurance company’s request and give you the option to decide what, if anything, may be released.  It is your choice whether or not to use your insurance coverage for payment of our services.

All personnel (clinical, support, or billing) authorized to have access to your information in this office will limit their access and use of your healthcare information to only what is necessary.  They have agreed to carefully abide by the privacy practices of this office.

If you are receiving clinical services from other health care professionals, we will need to routinely confer with them about your diagnosis, treatment plan, and progress for the purpose of coordinating your treatment.

At times, we may also seek out professional consultation about some aspect of our work with you.  Usually it will not be necessary to share your identifying information with the consultant(s).  The consulting professional(s) also must abide by applicable laws and ethics and protect your confidentiality in all cases.

Other than the routine disclosure noted above which are necessary to perform treatment and billing services on your behalf, no information will be released to any other persons or agencies outside of this office without your written authorization except by court order.  If anyone outside of this office requests information from us or from your records, your permission in writing on a special “authorization for release of information” form is necessary.  Before giving permission, satisfy yourself that the information is really needed, that you understand the information being sent out, and that giving the information will help you.  You have the right to approve or refuse the release of information to anyone, except as provided by law.

Exceptions to the Above Information Release Procedures:

1.    When we have knowledge of, or reasonable cause to believe, that a child/adult is being neglected or physically or sexually abused, in which case state law requires that information be reported to authorities.

2.    Reporting of maltreatment of vulnerable adults as specified in state law.

3.    Reporting of alleged practitioner sexual misconduct as specified in state law.

4.    Reporting of instances of threatened homicide or physical violence against another. We must report such threats to the appropriate police agency as well as to the intended victim.

5.    In cases of threatened suicide, at least one concerned person and/or the appropriate police agency may be contacted to intervene and the client will be referred for evaluation.

6.    In cases in which a client, with a history of sexual and/or physical abuse of others, terminates therapy against our advice, we will notify those past victims of abuse that the client has terminated therapy against our advice so that proper precautions can be taken.

7.    It is our policy to employ the use of a collection agency or to file in small claims court on all accounts which are overdue by 90 days.  Information necessary to pursue such payment due to me will be shared with the agency or court.

Right Not to Be Discriminated Against: You have the right not to be discriminated against in the provision of professional services on the basis of race, age, gender, ethnic origin, disability, creed, or sexual orientation.

Right to Know Your Providers Qualifications: You are entitled to ask us what your providers training is, where it was received, if they are licensed or certified, their professional competencies, experience, education, biases or attitudes, and any other relevant information that may be important to you in the provision of services.  You have the right to expect that we have met the minimum qualifications of training and experience required by state law and to examine public records maintained by the licensure boards that regulate our practice at 1373 Fillmore St, Twin Falls, ID, 83301.

Right to Be Informed: You have the right to be informed of our assessment of your problem in a language you understand, and to know available treatment alternatives.  You also have the right to understand the purpose of the professional services, including an estimate of the number of sessions, the length of time involved, the cost of the services, the methods used, and expected outcome of treatment.  In addition, you have the right and responsibility to help develop your own treatment plan.

Right to Read Your Own Records: You have the right to read your own records created by our agency with a provider assisting you. Under HIPPA regulations if we believe that the information that is contained in the file would be detrimental to your further treatment process then we have the right to withhold information with an explanation provided to you.  We will assist you in understanding your written records by being available to answer questions and to explain the meaning of test scores and technical terminology.  You may inform us of any inaccuracies of information in your file and give us a written amendment, which we will place in your file.  In addition, you have the right to be told why the information we are requesting is needed and be told how the information will be used.  You should also be informed of the consequences, if any, of refusing to supply requested information.  The information collected will be used by us for evaluation and treatment purposes.  If you choose to not supply such information, we cannot determine which services are most appropriate for you and that will make it more difficult for us to carry out an effective treatment plan for you.  Refusal to provide such information could result in our inability to provide effective treatment for you and we have the right to refuse treatment.  If this occurs we will provide you with a list of available resources to assist you.

Our records retention policy is as follows: The complete record will be retained for five years.  At the end of five years, the record will be entirely destroyed, leaving only the name of the client and date of record destruction.  The time period begins from the date of the last visit.  Should there be any further direct client contacts; the counting period will begin again at the date of the new service.

Right to Refuse Treatment: You have the right to consent or refuse recommended treatment.  You can be treated without consent only if there is an emergency, and in our opinion failure to act immediately would jeopardize your health.  In such emergency cases, we will make reasonable efforts to involve a close relative or friend prior to providing emergency services.  No audio or video recording of a treatment session can be made without your written permission.

Right to Voice Grievances: You have the right to voice grievances and request changes in your treatment without restraint, interference, coercion, discrimination, or reprisal.  We encourage you to share your concerns directly with us.  You have the right to report violations of our privacy practices to the Secretary of Health and Human Services. People with developmental and mental disabilities are entitled to protection and must have access to advocacy in securing the benefits, services and rights to which they are entitled. The following are resources which persons with developmental or mental disabilities may call upon:

Advocacy
	-Idaho Parents Unlimited, Inc.: 1-800-242-4785, V/TT 208-342-5884
	-Idaho Federation of Families: 1-800-905-3436 or 208-734-2303, www.idahofederation.org
	-Disability Rights Idaho (Formally Co-Ad): /TT: 208-336-5353, V/TT: 1-800-632-5125
	-In addition to: Targeted Service Coordinators, Legal Aid Services, Inc., Private Attorneys,  Family Members or Friends
Protection
	-Children and Family Services: 208-734-4000
	-Adult Protection Services: 208-736-2122
	-Law Enforcement Agencies
	-Mental Health Liaison: 208-732-1510

Right Not to Be Subjected to Harassment: You have the right to not be subjected to sexual, physical, or verbal harassment.

Minors’ Right to Privacy: All non-emancipated minor clients under the age of 18 must have consent of their parents or guardians following an initial intake session to receive further treatment services.  State law provides that minors have the right to request that their records be withheld from their parents or guardians.  If a minor client requests that records be withheld, and we concur that the denial of parental access is in the best interests of the child, information in the minor’s file will not be disclosed to the parents.  We may deny a parent’s or legal guardian’s request for access to his or her child’s treatment record when, in our professional judgment, parental or guardian access to the record would result in harm to the child.

Rights of Adults Judged Unable to Give Informed Consent: For adults judged unable to give informed consent, the same policy as that for minors (see above) applies regarding permission for services and requests that records be withheld.

Referral Rights: You have the right to be referred or terminated.  You have the right to active assistance from us in referring you to other appropriate services.

YOUR RESPONSIBILITIES AS A CLIENT

To Be Honest: You are responsible for being honest and direct about everything that relates to you as a client.  Please tell us exactly how you feel about the things that are happening to you in your life.

To Understand Your Treatment Plan: You are responsible for understanding your treatment plan to your own satisfaction.  If you do not understand, ask us.  Be sure you do understand since this is important for the success of the treatment plan.

To Follow the Treatment Plan: It is your responsibility to discuss with us whether or not you think and/or want to follow a certain treatment plan.

To Keep Appointments: You are responsible for keeping appointments.  If you cannot keep an appointment, notify us as soon as possible so that another client can be seen.  In any case, you will be charged for appointments when canceled with less than 24 hours’ notice as outlined in the Financial Policy.

To Know Your Fee: We are willing to discuss our fees with you and to provide a clear understanding for you of the costs of all associated service.

To Keep Positive Connections Plus Informed: So that we may contact whenever necessary, we will rely upon you to notify us of any changes in your name, address, and home or work phone numbers.

YOUR THERAPIST’S RIGHTS AND RESPONSIBILITIES

We have the responsibility to provide care appropriate to your situation, as determined by prevailing community standards.  To accomplish this goal, we also have certain rights, including:

1.    The right to information needed to provide appropriate care.

2.    The right to be reimbursed, as agreed, for services provided.

3.    The right to provide services in an atmosphere free of verbal, physical, or sexual harassment.

4.    The right and ethical obligation to refuse to provide services that are not clinically indicated.

EMERGENCY PROCEDURES

Should you feel that your situation requires immediate attention, we are available to return your phone calls from 8:00 a.m. to 5:00 p.m. at 208-737-9999, Monday through Friday.  You may call our crisis phone at 208-308-3883, between 5:00 p.m. to 8:00 a.m. Monday through Friday and 24 hours on Saturday and Sunday, we check our messages throughout the day. If you feel that you are in a crisis and need to talk to someone immediately at night, during the weekend or a holiday, and we are not immediately available, you may call Canyon View Hospital at 208-814-1000 or 911.  If you do speak with us, you may be billed at our current hourly rate for individual therapy for the time we spend with you on the phone.  You should be advised that your insurance company may not reimburse you for the telephone consultation charge.

NOTICE OF PRIVACY PRACTICES

Your Private Health Information

Our office keeps records of the mental health care and services provided to you in order to help provide quality care and services.   Because of the sensitivity of health records, we are required by state and federal law to maintain the privacy of your health information.  We are also required to give you this Notice of Privacy Practices concerning your health information.

Use and Disclosure of Information

We use and disclose information about you for treatment, payment and health care operations.  For example:

• Treatment: We may share all or part of your health information with another health care provider providing treatment to you.
• Payment: Our office keeps billing records that include payment information and documentation of the services provided to you.  We may use and disclose your health information to obtain payment from you, your insurance company, Medicaid, or other third party payment provider.
• Health Care: Operations We may use and disclose your health care information to improve quality of care, train our staff, provide customer service, mange costs and conduct business duties.

Federal guidelines do not require our office to have your written consent to disclose your health care information when it is for payment, treatment or health care operation purposes.  However, because your private health information is sensitive, we will keep disclosures to a minimum based on our professional judgment.  We will also have you sign a consent and/or authorization document to request information from other sources and to release health information to outside parties.

HIPAA and Your Privacy

The Health Insurance Portability Accountability Actwas enacted to maintain the confidentiality of personal medical information.  You are entitled to request information about your records or about the privacy of your information, or revoke your authorization at any time with a written request.                           

HIPAA permits us to disclose your health information without your written consent when it is for treatment payment or health care operations.  Protecting your privacy is important to us.  We follow federal and state laws, professional codes of ethics and industry best practices to provide the highest quality care.  

Information may be disclosed to family members or others directly involved in your care or payment for your care without your written consent.  Examples include parents of dependent children, legal guardians, and assisted     living/nursing home staff, Social Security Disability Officer, Worker’s Compensation, and Medicaid.

Third parties having access to your personal medical information must follow physical, electronic, and procedural safeguards that comply with HIPAA protections for confidentiality.

Other limited situations allowing us to use or disclose health information without your signed authorization include:

• Public health purposes such as reporting communicable diseases, work-related illnesses, or reporting adverse reactions to medication, etc.
• Protection of victims of abuse, neglect or domestic violence
• Health oversight activities such as investigations, audits and inspections
• Requests from a court order
• Worker’s Compensation
• Reduction or prevention of a serious threat to public health and safety

*We reserve the right to make changes to this notice and to make the privacy practices effective for all information we maintain.  Current notices will be posted in our office.  You may also request a copy at any time.