INFORMED CONSENT FORM

AND INFORMATION ON PROTECTING THE PRIVACY OF THE

CONSUMER'S PROTECTED HEALTH INFORMATION (PHI)

By completing and returning the INFORMED CONSENT SIGNATURE FORM to Catherine Stone, MSW, LISW-CP., I am stating that I have read the form, that I agree to all the conditions stated in the form and in the links, and that I agree to abide by all the conditions in the content of the Informed Consent Form and the links on this Web-site.

1.  I understand that entering into a counseling relationship with Catherine Stone, MSW, LISW-CP. is entirely voluntary on my part and that I may leave the relationship at any time.  If Catherine Stone feels that the counseling relationship is not in my best interest, she reserves the right to end the relationship making every attempt to safeguard my mental health status, to refer me to another counselor/therapist, and to continue to provide behavioral health support and care for me and not abandon me as a client.

2.  I understand that I am expected to participate with honesty and integrity in the counseling relationship as it benefits me. I am expected to keep appointments and to notify Catherine Stone for re-scheduling when necessary. At such time as I wish to terminate the counseling relationship, I will give Catherine Stone at least two weeks notice and will schedule a final, closing session.

3.  I understand that Catherine Stone will provide counseling in her areas of expertise.  Catherine Stone will do everything possible to secure a referral for any client she does not feel qualified to counsel.  Catherine Stone will respond to emails within 24 hours or make arrangements to set a time when the email will be answered.  Catherine Stone will also do everything possible to respond to emergencies. 

4.  I understand that there is no guarantee of results from counseling that will fulfill my wishes, such as re-uniting with a spouse, getting a job, etc. 

5.  I understand that certain risks are a part of any counseling relationship and that Catherine Stone will do everything possible to minimize those risks. 

6.  I understand that all correspondence between myself and Catherine Stone is privileged and confidential, and that I own any records or counseling notes that Catherine Stone maintains about our counseling relationship.  Authorization for disclosure of Protected Health Information (PHI) or counseling notes is by my written permission and that this authorization is above and beyond the general consent that permits only specific disclosures. I understand that except in certain circumstances explained below, Catherine Stone will not discuss our correspondence with anyone else or disclose to anyone else that I am a client of hers.  I understand that Catherine Stone will do everything to protect my rights of confidentiality.  In the case that I am in the care of a medical doctor, psychiatrist, or clinical psychologist for medication, I understand that Catherine Stone may request written permission to contact my medical doctor, psychiatrist, or clinical psychologist to consult with him or her.

7. I understand that use or disclosure of my Protected Health Information ( PHI ), for treatment, payment, and behavioral health care operations purposes will only happen with my consent except under conditions explained below. Definitions of terms are:

Treatment: Treatment is considered to be efforts to provide and coordinate my behavioral health care and other services related to behavioral health care.

Payment: When Catherine Stone obtains reimbursement for my behavioral health care, payment is involved. 

Behavioral Health Care Operations are activities that relate to the performance and operation of Catherine Stone's counseling practice such as correspondence with an insurer or managed care case manager. 

A Fact Sheet about PHI and Private Policy Information Sheet is available on request.

HIPAA policy: http://www.hhs.gov/ocr/hipaa/privacy.html

http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act

Protected health information means individually identifiable health information that is: 

1. Transmitted by electronic media; 
2. Maintained in any medium described in the definition of electronic media; or 
3. Transmitted or maintained in any other form or medium. 

Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and: 

1. Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and 
2. Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and 
1. That identifies the individual; or 
2. With respect to which there is a reasonable basis to believe the information can be used to identify the individual. 

Identifiers

The following are considered identifiers and can pertain to the individual or to relatives, employers, or household members of the individual:

1. Names;
2. All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census:
1. The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and
2. The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000.
3. All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older;
4. Telephone numbers;
5. Fax numbers;
6. Electronic mail addresses;
7. Social security numbers;
8. Medical record numbers;
9. Health plan beneficiary numbers;
10. Account numbers;
11. Certificate/license numbers;
12. Vehicle identifiers and serial numbers, including license plate numbers;
13. Device identifiers and serial numbers;
14. Web Universal Resource Locators (URLs);
15. Internet Protocol (IP) address numbers;
16. Biometric identifiers, including finger and voice prints;
17. Full face photographic images and any comparable images; and
18. Any other unique identifying number, characteristic, or code

8. I understand that I may revoke all authorizations (of PHI or counseling notes) granted to Catherine Stone at any time, provided each revocation is in writing. I understand that I may not revoke an authorization to the extent that (1) Catherine Stone has relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. I understand that counseling notes are kept separately, kept confidential, and kept secure as under physically locked circumstances at all times.

9.  I understand that for the following reasons, Catherine Stone may have to break confidentiality: report of child abuse to any child, intent to harm myself, intent to harm someone else, and elder or vulnerable adult abuse.  Also, in the state of South Carolina, a judge may issue a court order to compel a therapist to answer questions in court regarding behavioral health care.  Catherine Stone will disclose to the appropriate law enforcement agency or the SC Dept of Social Services, any instances of the above stipulated situations reported to her.

10. I understand that Catherine Stone uses several counseling approaches and theories and will discuss these with me upon my entering counseling with her and from an open, ethical, and honest perspective of personal integrity.

11.  I understand that I may have access to any and all financial records that Catherine Stone maintains concerning my financial transactions with her for counseling services received. 

12. I understand that Catherine Stone holds a current license as a Licensed Independent Social Worker in the State of South Carolina granted by the SC Board of Social Work Examiners, License number 6430.  

13.  I understand that I am responsible for payment of fees for counseling according to number of sessions as described in the Fee Schedule link on this Web site (http://betterthinking-betterlife.com) or as stipulated by a third party payor.  I understand that when I pay for my own counseling services, I may apply for reimbursement of fees upon submission of a letter explaining the necessity and circumstances of a reimbursement.  I understand that I am responsible for payment of fees for services at the time services are rendered unless my fees are paid by a third party in which case I may have to pay a co-payment if required by my behavioral health care insurer. In the case of my paying for counseling services, I understand that I will recieve monthly statements if there is a balance on my account and  payments will  incur a late fee of $15.00 per month for payments not made within 30 days of statement date.  Failure to pay fees promptly will result in cessation of counseling services, and if necessary, I will be notified by registered letter of cessation of services and ending of the counseling relationship. In the case of cessation of services, I understand that Catherine Stone will attempt to make an appropriate referral for counseling services.

14.  I understand that I may seek redress from licensure and certifying boards for disputes in services or fees.

 
15.  I understand that cancellation of appointments must be received by Catherine Stone at least 48  hours before the session.  Cancellations without appropriate notice will be subject to a fee of $45.

  
16.  I understand that Catherine Stone may consult with  peer colleagues who are counselors and that Catherine Stone will not disclose any confidential information, counseling notes, or PHI to consulting colleagues without my written permission.  I understand that Catherine Stone as my counselor may from time to time seek professional consultation concerning counseling with me and that this consultation will be strictly confidential and will protect my rights of privacy and PHI.

17. I understand that Catherine Stone is required by law to maintain the privacy of PHI and to provide me with a notice of my legal duties and privacy practices with respect to PHI.  Catherine Stone reserves the right, within federal and state government laws and policies, best counseling practices, and ethical standards of all professional organizations to which she belongs, to change the privacy policies and practices described in this notice. Unless she notifies me of such changes, however, Catherine Stone is required to abide by the terms currently in effect.   If she revises the informed consent form, Catherine Stone will notify me at our next counseling session.

18. Questions and Complaints

If I have questions about this notice, disagree with a decision Catherine Stone makes about access to my records, or have other concerns about my privacy rights, I understand that I may contact Catherine Stone to further discuss these issues.  If I believe that my privacy rights have been violated and wish to file a complaint with a governing office, I may send my written complaint to the organizations already listed above and may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services at:

The U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
Telephone: 202-619-0257
Toll Free: 1-877-696-6775

I understand that I have specific rights under the Privacy Rule and that Catherine Stone will not retaliate against me for exercising my right to file a complaint.

19. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 1, 2007.  Any limits on the uses or disclosures that Catherine Stone will make will be completed separately.  Catherine Stone reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that she maintains.  I agree to the stipulations and explanations described above and agree to abide by the guidelines so described.

Please click HERE to open the signature page.  Please print the signature page and bring it to my office at the first session. 

Thanks,

Cathy Stone, MSW, LISW-CP