JP Counseling & Associates, LLC
Provider Services Agreement and Consent For Care
Welcome and congratulations on taking the first step toward positive change. We look forward to working with you and helping you with healing and growth.
This Services Agreement and Consent for Care (hereinafter “Services Agreement”) contains important information about our professional services and business policies. Please read it carefully. It is important that you have a clear understanding of why you are receiving services and how we are attempting to assist you with your care. If you are uncertain at any time regarding your treatment, please contact us immediately. This Services Agreement explains the office policies, procedures, and practices. You will be asked to sign indicating that you have read, have understood, and accept the Services Agreement and any and all other documents JP Counseling & Associates, LLC (hereinafter “JPC”) has included.
The counseling process is not easily described in general statements. It varies depending on the personalities of the counselor and the client, their dynamics together, and the issues being explored. There are many different methods we have been trained to use as counselors to help you deal with the reasons you came to therapy. It is our philosophy to always be kind and respectful, but also to be direct and honest. Counseling requires a very active effort on your part. For therapy to be most successful, you will have to work on things we talk about both during our sessions and outside of them.
Counseling has both benefits and risks. Significant benefits include better relationships, solutions to specific problems, and reductions in feelings of distress. Since therapy often involves discussing difficult or unpleasant aspects of life, you may also experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, or helplessness. Each individual’s experience is unique, and any services offered will be tailored to suit the client’s needs.
Initial sessions will involve evaluation of your needs and motivation for counseling, as well as an evaluation of your level of comfort working with JPC. Therapy involves a large commitment of time, money, and energy and, therefore, you should be very judicious about the therapist you select. If you have questions about JPC procedures or philosophy, you should discuss them with us whenever they arise.
If at any time you do not think JPC is a good fit to continue working together, we will be happy to help you set up a meeting with another mental health professional. In most cases, the counseling process is voluntary and can be terminated at any time by either party. If JPC decides to terminate the counseling relationship, we will do our best to explain the reasons why and to make a referral to another clinician.
As a client of JPC, you have the right to services free from abuse, financial or other exploitation, retaliation, humiliation, or neglect. If you believe you are experiencing any of these things, even if you are not fully certain, or if you ever have any complaints about your therapist or our practice, please do not hesitate to contact our president, Jill Perry at 724-494-6750 or email@example.com
JP Counseling & Associates, LLC reserves the right to change the practices described or terms of this Services Agreement at any time. If changed, you may receive a new Services Agreement electronically.
Therapy sessions vary in length, usually from 45-55 minutes, based on several issues, including insurance. Initially, sessions are usually scheduled weekly but frequency may vary.
CONTACTING US & CLIENT EMERGENCIES
Due to our work schedule, we are often not immediately available by telephone. When we are unavailable, our telephone is answered by a voicemail which we monitor frequently. We will make every effort to return your call within 24 hours, with the exception of weekends and holidays. If you are difficult to reach, please inform us of times when you will be available for us to return the call.
JP Counseling & Associates, LLC does not provide on call, after hours, or emergency services. We are solely an outpatient practice providing services by appointment only. In the event of a medical emergency or an emergency involving a threat to your safety or the safety of others, please call 911, go to your nearest emergency room or contact crisis services in your area:
- Beaver County, PA, Crisis 1-800-400-6180
- Allegheny County, PA, Crisis Resolve 1-888-796-8226
- Butler County, PA, Crisis 1-844-427-4747
- https://www.crisistextline.org Text HOME to 741741
CLIENT COMMUNICATIONS & PUBLIC CONTACT
To facilitate communication, we require all clients to provide us with a valid home address, telephone number and email that we may use to contact you. We encourage you to avoid providing contact information associated with your employment to help protect your privacy, as JPC is not liable for breaches of privacy associated with the contact information you provide.
Email communication will be sent through HIPAA compliant email whenever possible, but some exceptions, such as our appointment reminder system, do not have this option.
By signing the last page of this document, you give our clinical and administrative personnel authorization to contact you for scheduling and billing purposes at the addresses provided. By signing this client agreement, you also acknowledge and give permission for JPC to include private health information in these communications.
CANCELLATION & NO SHOW POLICY
Once an appointment session is scheduled, you will be expected to provide 24 hours advance notice of cancellation. If you do not follow this procedure, or if you do not show, you will be charged $40 for the session. Insurance will not pay or reimburse for late cancelled or no show sessions, and you agree that payment will be your responsibility.
INSURANCE & PROFESSIONAL FEES
Insurance companies require information about you in order to authorize or pay for services. This information may include a clinical diagnosis, treatment plans, or progress updates. By signing this Agreement, you agree that we can provide requested information to your insurance company or funding source that will pay for the service.
It is YOUR responsibility to know your insurance coverage and to notify JPC of any changes to your insurance, coverage, or policy. Any services provided that are not covered by your insurance company are your financial responsibility and are subject to our standard collection procedures.
If your clinician is not individually contracted with your insurance company, your insurance is considered “out of network.” This means that it may be subject to a different set of deductibles, co-pay formulas, and limits on coverage and we cannot guarantee your insurer will reimburse you for your care. Clients wishing to use out-of-network insurance coverage must pay their therapist’s rate at the time of service. We DO NOT submit claims on an out of network basis for our clients. JPC can provide you with a "superbill" that you can personally submit to your insurer. In the event that your out-of-network insurance coverage fails to cover your care, you will be held liable for our standard rate.
Copays, coinsurance and session fees for non-insurance clients are due at the time services are rendered.
Payments accepted by cash, check or credit/debit card. JPC can also secure your credit/debit card information electronically for regular payments. Clients with high deductibles and all telehealth sessions are required to pre-pay and have a credit card on file.
In the event that your card is declined, our office will continue to attempt to process your card (including partial amounts) at our discretion for up to 180 days after your appointment. We are not responsible for fees associated with bank account, including overdraft fees, or delayed processing of your credit card.
In the event a client contests a valid charge resulting in a reversal or chargeback initiated by their bank/card issuer, JPC will assess a client's account $50 to cover the cost charged by our bank/credit card processor and the additional labor involved with collecting their outstanding balance.
Failure to pay any fees within 60 days of the date of service will result in your private information being turned over to the law firm or collection agency of our choice for collection actions, including the possible filing of a public lawsuit for collections. This may result in the disclosure of some aspects of your private health information. Fees associated with collections will be added to the balance you owe to our practice.
Fees for services may vary depending on contracts with insurance and other payers. You can ask us to see our rates. In addition to regular appointments, we charge $150/hour for other professional services you may need, although we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, attendance at meetings with other professionals you have authorized, preparation of records of treatment summaries, and the time spent performing any other service you may request of us. Insurance will not pay or reimburse for these additional service fees, and they will be your responsibility. Fees must be paid in full before the service will be completed.
By signing this document, you agree to pay in advance should we be asked to testify in any type of court proceeding, including but not limited to any type of court trails including divorce or custody cases, depositions, mediations, etc. You agree to pay this fee even if another attorney, without your authorization, subpoenas any of our staff regarding your records. Because of the intensity of legal involvement, we charge $400 per hour for preparation, attendance, and travel at any legal proceeding.
JPC strictly prohibits audio or video recording of any therapy without all parties' expressed written consent. By signing this document, you also agree to pay a fee of $2,000 for each session in which you record all or part of the session without our clinician's expressed written consent.
CONFIDENTIALITY & RIGHT TO RESPOND TO COMPLAINTS, REVIEWS AND MEDIA
In the event that you exercise your right to create an online review, file a complaint with any regulatory body, or engage in commentary in the media about our practice, clinicians or your treatment, you also waive your right to confidentiality. By signing this agreement, you give JP Counseling & Associates, LLC permission to respond publicly and privately to any such complaints in the course of protecting its reputation, defending its ethics, or clarifying facts related to your treatment.
The laws and standards of our profession require that we keep Protected Health Information (PHI) about you in a Clinical Record. This includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultation, your billing records, and any reports that have been sent to anyone. You are entitled to receive a copy of your records, or we can prepare a summary for you instead. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. If you wish to see your records, we recommend that you review them in our presence so that we can discuss the contents. Patients will be charged an appropriate fee for any professional time spend in responding to information requests.
AGE OF CONSENT
A juvenile age 14-17 can consent to outpatient mental health examination and treatment for him/herself without parental consent. A parent or legal guardian of a juvenile under age 18 can also provide consent without the juvenile’s consent under certain circumstances.
The law protects the privacy of all communication between a patient and a counselor. In most cases, we can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by the Health Insurance and Portability and Accountability Act (HIPAA). There are other situations that require written, advanced consent, such as professional consultations. Your signature on this Services Agreement provides consent for consultation with other health and mental health professionals. During these consultations, we make every effort to avoid revealing the identity of the client. The other professionals are also legally bound to keep the information confidential.
There are some situations in which we are legally obligated to take actions that we believe are necessary to attempt to protect you or others from harm, and that may require us to reveal some information about treatment. These situations are rare in our practice but include the following:
- If we have reason to believe that a child, elder, or disabled person is being abused.
- If we believe a client presents a serious, specific, and immediate threat of serious bodily injury regarding a specifically identified or a reasonably identifiable victim and that he/she is likely to carry out the threat.
- If we believe a client seriously threatens to harm him/herself.
There are some situations in which we are legally permitted or required to disclose information without either your consent or authorization. These situations include the following:
- If you are involved in a court proceeding and a request is made for information concerning the professional services we provided to you, such information is protected by the privilege law. We cannot provide any information without your written authorization or a court order. If you are involved in, or contemplating, litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
- If you file a complaint or lawsuit against us, we may disclose relevant information regarding your treatment for our defense.
- If an appropriate request is made regarding a worker’s compensation claim for you, we may be required to provide otherwise confidential information to your employer.
If any of these situations should arise, we will make every effort to fully discuss it with you before taking any action whenever possible, and we will limit disclosure to only what is necessary.
Because our staff are experts in the field of mental health, they may conduct trainings for students, trainees, practitioners, or the community. At times, we may use your de-identified information for teaching purposes as permitted by the Privacy Rule under HIPAA utilizing the Safe Harbor Method of De-identification.
While this written summary of exceptions to confidentiality should prove helpful in providing you with information about potential problems, it is important that you discuss any questions or concerns that you have now or in the future with JPC.
BILLING AND PAYMENTS
Payments must be paid for each session/service before or at the time of the service. If your account has not been paid for more than 60 days, and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. These legal means may involve hiring a collection agency, going through small claims court and/or filing a claim in Magistrate Court, all of which may require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of the services provided, and the amount due. If such legal action is necessary, all costs of such legal action will be included in the claim.
Telehealth, including video and phone sessions, may be available to you depending on your individual insurance plan. It is YOUR responsibility to know your insurance coverage. In order to protect the therapeutic process, you will need to be in a private room by yourself where you feel comfortable that no one can interfere with your telehealth session. You will need a device with a video camera, speakers and microphone (ie—computer, tablet, cell phone). Your therapist will also be in a private room but at another location with the same type of equipment. By signing this agreement, you agree that you understand the risks and benefits of telehealth, including partial or complete failure of the equipment being used which could result in the therapist’s inability to complete the session. If you have any concerns at any time, talk with your therapist.
JPC utilizes a HIPAA-compliant telehealth platform, and there is no video or voice recording of any telehealth sessions.