Client Handbook

Mental Health Rights and Patient Responsibilities

We recognize that each patient has the right to the following:

Use and Disclosure of Protected Health Information:

For Treatment - We use and disclose your health information internally in the course of your treatment.  If we wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information.  Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.

For Payment - We may use and disclose your health information to obtain payment for services we provide to you.

For Operations - We may use and disclose your health information within Willow Tree Therapy Services, LLC as part of our internal operations.  For example, this could mean a review of records to assure quality.  We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.

Patient's Rights:

Right to Confidentiality - You have the right to have your health care information protected.  If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  We will agree to such unless a law requires us to share that information.

Right to Request Restrictions - You have the right to request restrictions on certain uses and disclosures of protected health information about you.  However, we are not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI.  Records must be requested in writing and release of information must be completed.  Furthermore, there may be a copying fee charge of $1.00 per page.  Please make your request well in advanced and allow 2 weeks to receive the copies.  If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request. 

Right to Amend - If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information.  You have to make this request in writing.  You must tell us the reasons you want to make these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.  

Right to a copy of this notice - If you received the paperwork electronically, you have a copy in your email.  If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time. 

Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI regarding you.  On your request, we will discuss with you the details of the accounting process.

Right to choose someone to act for you - If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.  

Right to Choose - You have the right to decide not to receive services with us.  If you wish, we will provide you with names of other qualified professionals.  

Right to Terminate - You have the right to terminate therapeutic services with us at any time without any legal or financial obligations other than those already accrued.  We ask that you discuss your decision with your therapist in session before terminating or at least contact your therapist or their supervisor by phone letting them know you are terminating services. 

Right to Release Information with Written Consent - With your written consent, any part of your record can be released to any person or agency you designate.  We will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you. 

Therapist’s Duties:

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.  We reserve the right to change the privacy policies and practices described in this notice.  Unless we notify you of such changes, however, we are required to abide by the terms currently in effect.  If we revise our policies and procedures, we will provide you with a revised notice in office during your session.

Grievance Procedures

You can send us any feedback, complaints, etc. to Amanda@willowtreetherapyservices.org

If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may file a complaint with the person listed below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue SW, Washington D.C., 20201. We will take no retaliatory action against you if you make such complaints.

Florida Patient's Bill of Rights Consumer Assistance Notice

For concerns about your HMO or medical care call:
(Si tiene preoccupaciones sobre su seguro HMO o su cuidado medico, llame a:)

HMO/MANAGED CARE HOTLINE 1-800-226-1062
Agency for Health Care Administration
2727 Mahan Drive, Building 1, Mailstop #27
Tallahassee, FL 32308

DEPARTMENT OF INSURANCE CONSUMER 1-800-342-2762
SERVICES HELPLINE
Division of Consumer Services
200 E. Gaines Street
Tallahassee, FL 32399-0322

HEALTH CARE CONSUMER 1-850-921-5458
ASSISTANCE HOTLINE
The Statewide Provider and Subscriber Assistance Panel
2727 Mahan Drive, Building 1, Mailstop #27
Tallahassee, FL 32308

If you require assistance in obtaining the address and toll free telephone number of your HMO's Grievance Department please ask the staff of this office to assist you.

Statewide Consumer Call Center

Consumer Complain, Publication and Information Call Center - 888-419-3456 / 800 - 955-8771 (TDD Number)

• Option 1 - Available Monday - Friday, 8:00 A.M. to 5:00 P.M., EST. To file a complaint about a health care facility, such as a hospital, nursing home, assisted living facility, home health agency, or other type of health care facility. Your patient care complaint may also be filed at any time, by completing the Health Care Facility Complaint Form. Please search our FloridaHealthFinder.gov site to see if the facility you have concerns about is one that is regulated by our Agency

• Option 2- To obtain general information about Medicaid or to report Medicaid Fraud. If you’re calling about the services provided under your Medicaid health insurance plan, such as transportation, dental services or prescription coverage, or if you want to change your plan, you may also reach our Medicaid Contact Center directly at 1-877-254-1055.
  To find out if you qualify for Medicaid services, need a replacement Gold card, need to add a family member, or want information about the Medically Needy Program, please call the Department of Children and Families at 1-866-762-2237.

Option 3 - Available Monday - Friday, 8:00 A.M. to 5:00 P.M., EST. To file a complaint against a health maintenance organization (HMO). If you are having problems with the HMO's internal grievance process. If you have completed the internal grievance process and wish to appeal. If you need referral numbers to member services or the grievance coordinators.

Access to Services:

Counseling services are generally available during normal business hours (Monday - Friday from 9 AM - 6 PM) throughout the year, except on designated holidays. If it is after office hours and you are in a medical emergency please call 911 or visit your local emergency room. If you are experiencing a mental health crisis and would like to speak to someone immediately, you may contact the following numbers

(877) 870-4673 (HOPE). For youth, contact 800-448-3000. I will notify you in advance with any office closures in the event of an emergency (e.g., natural disaster, health emergency) that requires office closure.

Fees

Fees are charged for services rendered on behalf of Willow Tree Therapy Services, LLC. The fee schedule is as follows if you are opting to not bill your insurance company (e.g., pay out of pocket): • Intake/Assessments/Evaluations (up to 120 minutes): $140 • Individual sessions (45 minutes $80 or 60 minutes - $110) • Family sessions (90 minutes - $140) • Court appearances: $200 per hour (door to door), paperwork processing for court hearings will be charged at $250 per hour.  These fees will be required before services are rendered. At this time, I will no longer offer a sliding scale fee.

If you request any letters, forms, or any other paperwork to be competed, such as FMLA or disability forms, please be advised that there is a fee for paperwork.  My fee is $90 per hour.  I will not complete any FMLA, disability, or other letters of support unless I have met with you for 6-8 sessions.  I will also not complete any FMLA or disability paperwork if I do not believe I can support it based on what you have presented at intake and during sessions.

Payment and Insurance Reimbursement:

You are fully responsible for the payment of all fees for services provided regardless of any insurance coverage you may have. You understand that it is Willow Tree Therapy Services, LLC policy that the fee for any session is payable at the beginning of the session. Willow Tree Therapy Services, LLC accepts cash, checks or credit cards as forms of payment. All sessions are 45 - 55 minutes in length. The fee for an initial intake session is $140.00. Follow up session fees for individuals (55 minutes - $110), (45 minutes - $75), Individual/Family Session (90 minutes - $140).  While sessions are not conducted by phone, if an emergency phone consultation is initiated by the client, the first 15-minutes are at no charge. However, $25.00 will be billed to your account for each subsequent 15- minute period. I understand that if I have insurance, Willow Tree Therapy Services, LLC will either file the claim on my behalf or will provide me with the necessary information so that I can file the claim. I understand that I am ultimately responsible for any therapy fee(s) not covered by my insurance carrier. Co-pays and non-covered services are payable at time of service unless other arrangements have been made. In the event that insurance is billed on my (the client) behalf, I authorize payment of mental health benefits to Willow Tree Therapy Services, LLC.

In the event of a lapse of insurance coverage; the client has three options. 

1. Continue with services and pay the full therapy fees as listed above.

2. Request a referral to a provider who accepts insurance or your preferred method of payment.

3. Request to be discharged from services.

No-Show/Late Cancellation Charge:

ppreciate prompt arrival for appointments. Please notify me at 904-349-5299 for any late arrivals. If a client does not provide notice within 24 hours of his/her scheduled appointment, a fee of $75 will be charged to the client’s account and will be asked to pay this balance prior to scheduling his/her next appointment. Clients may leave a message on Willow Tree Therapy Services, LLC voicemail to cancel an appointment; however this message must be left at least 24 hours before the scheduled appointment. If you are more than 15 minutes late for a session, your appointment may be cancelled and a fee will be added to your account. If we have a reoccurring appointment, I will wait for 24 hours after the missed appointment to confirm for the next scheduled appointment. If there is no contact, you will be discharged or placed on a waiting list. This is to ensure that you are not charged two times for a no-show fee.

If insurance prohibits this therapist from charging a no-show fee, I will allow one “no show” before I must consider the professional relationship discontinued, for ethical and legal purposes.  If court ordered, a summary outlining reason for discharge will be provided including dates of missed sessions.

NOTICE OF PRIVACY PRACTICES

Health Insurance Portability Accountability Act (HIPAA)

 Client Rights & Therapist Duties

 This document contains important information about federal law, the Health Insurance Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.  HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations.  The Notice, which is attached to this Agreement, explains HIPAA and its application to your PHI in greater detail.  The law requires that we obtain your signature acknowledging that we have provided you with this.  If you have any questions, it is your right and obligation to ask so we can have a further discussion prior to signing this document.  When you sign this document, it will also represent an agreement between us.  You may revoke this Agreement in writing at any time.  That revocation will be binding unless we have taken action in reliance on it.  

 LIMITS ON CONFIDENTIALITY

 The law protects the privacy of all communication between a patient and a therapist.  In most situations, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA.  There are some situations where we are permitted or required to disclose information without either your consent or authorization. If such a situation arises, we will limit my disclosure to what is necessary.  Reasons we may have to release your information without authorization:

1.    If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law.  We cannot provide any information without your (or your legal representative's) written authorization, or a court order, or if we receive a subpoena of which you have been properly notified and you have failed to inform us that you oppose the subpoena.  If you are involved in or contemplating litigation, you should consult with an attorney to determine whether a court would be likely to order us to disclose information.

2.    If a government agency is requesting the information for health oversight activities, within its appropriate legal authority, we may be required to provide it for them.

3.    If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.

4.    If a patient files a worker's compensation claim, and we are providing necessary treatment related to that claim, we must, upon appropriate request, submit treatment reports to the appropriate parties, including the patient's employer, the insurance carrier or an authorized qualified rehabilitation provider.

5.    We may disclose the minimum necessary health information to Valladares Therapy Services & Consulting business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  Our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm, and we may have to reveal some information about a patient's treatment:

1.    If we know, or have reason to suspect, that a child under 18 has been abused, abandoned, or neglected by a parent, legal custodian, caregiver, or any other person responsible for the child's welfare, the law requires that we file a report with the Florida Abuse Hotline.  Once such a report is filed, we may be required to provide additional information.

2.    If we know or have reasonable cause to suspect, that a vulnerable adult has been abused, neglected, or exploited, the law requires that we file a report with the Florida Abuse Hotline.  Once such a report is filed, we may be required to provide additional information.

3.    If we believe that there is a clear and immediate probability of physical harm to the patient, to other individuals, or to society, we may be required to disclose information to take protective action, including communicating the information to the potential victim, and/or appropriate family member, and/or the police or to seek hospitalization of the patient.