Office Policies, General Information & Informed Consent for Services
This form provides you, the patient, with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA preemptive analysis.
CONFIDENTIALITY: All information disclosed during office visits and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.
WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some circumstances where disclosure is required or may be required by law are: when there is reasonable suspicion of child, dependent, or elder abuse or neglect; if a patient presents a danger to self, to others, to property, or is gravely disabled; or when a patient's family members communicate to Progressive Mind Center, PLLC (PMC) that the patient presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the treatment records and/or testimony from PMC. In couples and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. PMC will use clinical judgment when revealing such information. PMC will not release records to any outside party unless they are mandated by court order or are authorized to do so by all adult parties who were part of the family therapy, couples therapy, or other treatment that involved more than one adult patient.
EMERGENCIES: If there is an emergency during treatment or after treatment termination and PMC becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, they will do whatever possible, within the limits of the law, to prevent you from injuring yourself or others and ensure that you receive the proper medical care. For this purpose, they may also contact the person whose name you have provided on the biographical sheet.
HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process claims. If you so instruct PMC, will provide only the minimum necessary information to be communicated to the carrier. PMC has no control over, or knowledge of, what insurance companies do with the information submitted or who has access to this information. You must be aware that submitting a mental health invoice to your insurance company for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health, life, disability insurance, or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access. Medical data has also been reported to have been legally accessed by law enforcement and other agencies, that also puts you in a vulnerable position.
LITIGATION: Sometimes patients become involved in litigation while they are in treatment or once treatment has been completed. Sometimes patients or the opposing attorney in a legal case wants the records disclosed to the legal system. Due to the nature of the this type of treatment and the fact that it often involves making a full disclosure with regard to many matters, patient records are generally confidential and private in nature. Patients should know that very serious consequences can result from disclosing treatment records to the legal system. Such disclosures may negatively impact the outcome of custody disputes or other legal matters and may negatively affect the doctor-patient relationship. If you or the opposing attorney are considering requesting disclosure of the records, PMC will do their best to discuss with you the risks and benefits of doing so. As noted in this document, you have the right to review your own treatment records anytime. (See also relevant section above: "WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW").
CONSULTATION: PMC may consult with other professionals regarding their patients; however, each patient's identity remains completely anonymous and confidentiality is fully maintained.
E–MAILS, CELL PHONES, COMPUTERS, AND FAXES: It is very important to be aware that computers and unencrypted email, texts, and e-fax communication (which are part of the clinical records) may be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. While data on PMC are encrypted, emails, texts and e-faxes are not. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. PMC laptops are equipped with a firewall, a virus protection and a password, and they back up all confidential information from their computers on a regular basis onto an encrypted hard-drive. Also, be aware that phone messages are transcribed and sent to PMC via unencrypted emails. Please notify PMC if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, we will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and staff will honor your desire to communicate on such matters. Please do not use texts, email, voicemail, or faxes for emergencies.
RECORDS AND YOUR RIGHT TO REVIEW THEM: Both, the law and the standards of PMC, require that they keep treatment records for at least 7 years. Please note that clinically relevant information from emails, texts, and faxes are part of the clinical records. Unless otherwise agreed to be necessary, PMC retains clinical records only as long as is mandated by Florida law. If you have concerns regarding the treatment records, please discuss them with PMC. As a patient, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when PMC assesses that releasing such information might be harmful in any way. In such a case, PMC provides the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, upon your request, PMC release information to any agency/person you specify unless PMC assesses that releasing such information might be harmful in any way. When more than one patient is involved in treatment, such as in cases of couples and family therapy, PMC only release records with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.
TELEPHONE & EMERGENCY PROCEDURES: If you need to contact PMC, between appointments and no one is available to answer your call, please leave a message at (772) 213-8881 and your call will be returned by the end of the next business day. PMC checks messages during business hours only. If an emergency situation arises, do not wait to contact the office. You are to immediately call 911, the area Police, or go to the nearest emergency room. You may also get assistance from Psychiatric Emergency Services 24-hour crisis line (Indian River County) by calling 211. Please do not use email or faxes for emergencies. PMC only checks emails or faxes on business days.
PAYMENTS & INSURANCE REIMBURSEMENT: Patients are expected to pay the standard fee for services prior to or at the beginning of each session unless other arrangements have been made. Telephone conversations more than 5 minutes in length, site visits, writing and reading of reports, consultation with other professionals, reading records, sessions that extend beyond allotted time, travel time, etc., will be charged at the same rate, unless indicated and agreed upon otherwise. Please notify PMC immediately if any problems arise during the course of treatment regarding your ability to make timely payments. Patients who carry insurance should remember that professional services are rendered and charged to the patient and not to the insurance companies. If requested, PMC will provide you with a copy of your receipt that you may submit to your insurance company for reimbursement, if you so choose. As was indicated in the section, “Health Insurance & Confidentiality of Records,” you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk. Not all issues/conditions/problems that are addressed in treatment are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, PMC, may use legal or other means (courts, collection agencies, etc.) to obtain payment.
THE PROCESS OF EVALUATION AND SCOPE OF PRACTICE: Participation in treatment can result in a number of benefits to you, including resolution of the specific concerns that led you to seek treatment. Working toward these benefits, however, requires effort on your part. Psychiatric treatment requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behaviors. PMC asks for your feedback and views on your treatment progress and will expect you to respond openly and honestly. Sometimes more than one approach may be helpful in dealing with a certain situation. During evaluation or ongoing treatment, remembering or talking about unpleasant events, feelings, or thoughts may result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. PMC may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations that may cause you to feel very upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that initially brought you into treatment may result in changes that were not originally intended. There is no guarantee that pharmacological and/or psychotherapy interventions will yield positive or intended results. During the course of treatment, PMC, is likely to draw on various treatment approaches according, in part, to the problem that is being treated and the clinician’s assessment of what will best benefit you. PMC provides neither custody evaluation recommendations nor legal advice, as these activities do not fall within the scope of this practice.
TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, PMC will discuss with you the clinician’s working understanding of the problem, treatment plan, therapeutic objectives, and view of the possible outcomes of treatment. If you have unanswered questions about any of the interventions used during the course of your therapy or possible risks, PMC’s expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
TERMINATION: As set forth above, PMC assesses if our treatment interventions may possibly benefit you. PMC will not work with patients who, in their opinion, cannot be helped by a physician or a physician extender, e.g., nurse practitioner, physician’s assistant. In such a case, if appropriate, the practice will give you referrals that you may contact. If at any point while receiving treatment at PMC, it is assessed that they are not effectively helping you reach your treatment goals, if you are non-compliant or non-responsive with recommended treatment, if you are assessed to require treatment in a higher level of care, and/or if you appear to be seeking pharmacological interventions for non-therapeutic use, and you are available and/or it is possible and appropriate to do so, the clinician will discuss with you the termination of treatment and conduct pre-termination counseling. In such a case, if appropriate and/or necessary, the practice will advise you of alternative providers that are able to provide similar services. If you request it and authorize it in writing, PMC will communicate with the provider of your choice to assist with the transition. If at any time you want another professional’s opinion or wish to consult with another psychiatrist, nurse practitioner, or physician’s assistant, PMC may provide other professional practices that you may choose to contact, and if the clinician has your written consent, s/he will provide the practice/practitioner with the essential information needed. You have the right to terminate therapy and communication at any time. If you choose to do so, upon your request and if appropriate and possible, PMC may provide you with names of other qualified treatment providers or treatment provider agencies whose services you might prefer.
DUAL RELATIONSHIPS: Despite a popular perception, not all dual or multiple relationships are unethical or avoidable. Treatment never involves sexual or other dual relationships that impair PMC’s objectivity or clinical judgment. PMC carefully assesses before entering into non-sexual or non-exploitative dual relationship with a patient. It is important to realize that in some communities, particularly small towns, small communities, military bases, university campuses, spiritual, and rehabilitation communities, etc., multiple relationships are unavoidable and expected. PMC never acknowledges working with anyone without his/her written permission. Many patients have chosen PMC for psychiatric interventions because they knew the practitioner before entering into a therapeutic relationship and/or are personally aware of his/her professional work and achievements. Nevertheless, PMC will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships. Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know which ahead of time. It is your responsibility to advise PMC if the dual or multiple relationship becomes uncomfortable in any way. PMC always listens carefully and responds to your feedback and will discontinue the dual relationship if the practitioner finds it interfering with the effectiveness of your treatment or welfare and, of course, you may do the same at any time.
SOCIAL NETWORKING AND INTERNET SEARCHES: At times, PMC may conduct a web search on a patient prior to beginning of treatment or during treatment. If you have concerns or questions regarding this practice, please discuss them with us. We do not accept friend requests from current or former patients on social networking sites, such as Facebook. We believe that adding patients as friends on these sites and/or communicating via such sites can compromise privacy and confidentiality. For this same reason, we request that patients not communicate with us via any interactive or social networking web sites.
AUDIO OR VIDEO RECORDING: Unless otherwise agreed to by all parties beforehand, there shall be no audio or video recording of therapy sessions, phone calls, or any other services provided by PMC.
CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.