Dr. Manjit Kaur Khalsa Ed.D.
to my practice. This document (the Agreement) contains important information
about my professional services and business policies. It also contains summary
information about the Health Insurance Portability and Accountability Act (HIPAA),
a new federal law that provides new privacy protections and new 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 I 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 personal health information in
greater detail. The law requires that I obtain your signature acknowledging that
I have provided you with this information at the end of this session. Although
these documents are long and sometimes complex, it is very important that you
read them carefully before our next session. We can discuss any questions you
have about the procedures at that time. 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 on me unless I have taken action in reliance on it; if there are
obligations imposed on me by your health insurer in order to process or
substantiate claims made under your policy; or if you have not satisfied any
financial obligations you have incurred.
is not easily described in general statements. It varies depending on the
personalities of the psychologist and patient, and the particular problems you
are experiencing. There are many different methods I may use to deal with the
problems that you hope to address. Psychotherapy is not like a medical doctor
visit. Instead, it calls for a very active effort on your part. In order for the
therapy to be most successful, you will have to work on things we talk about
both during our sessions and at home.
can have benefits and risks. Since therapy often involves discussing unpleasant
aspects of your life, you may experience uncomfortable feelings like sadness,
guilt, anger, frustration, loneliness, and helplessness. On the other hand,
psychotherapy has also been shown to have many benefits. Therapy often leads to
better relationships, solutions to specific problems, and significant reductions
in feelings of distress. But there are no guarantees of what you will
few sessions will involve an evaluation of your needs. By the end of the
evaluation, I will be able to offer you some first impressions of what our work
will include and a treatment plan to follow, if you decide to continue with
therapy. You should evaluate this information along with your own opinions of
whether you feel comfortable working with me. Therapy involves a large
commitment of time, money, and energy, so you should be very careful about the
therapist you select. If you have questions about my procedures, we should
discuss them whenever they arise. If your doubts persist, I will be happy to
help you set up a meeting with another mental health professional for a second
normally conduct an evaluation that will last from 1 to 3 sessions. During this
time, we can both decide if I am the best person to provide the services you
need in order to meet your treatment goals. If psychotherapy is begun, I will
usually schedule one 45 to 50-minute session (one appointment hour of 45 - 50
minutes duration) per week at a time we agree on, although some sessions may be
longer or more frequent. Once an
appointment hour is scheduled, you will be expected to pay for it unless you
provide 24 hours advance notice of cancellation [unless we both agree
that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do
not provide reimbursement for cancelled sessions. [If
it is possible, I will try to find another time to reschedule the appointment.]
current hourly fee is $150 - $200 per hour.. In addition to weekly appointments,
I charge this amount for other professional services you may need, though I will
break down the hourly cost if I work for periods of less than one hour. Other
services include report writing, telephone conversations lasting longer than 5
minutes, consulting with other professionals with your permission, preparation
of records or treatment summaries, and the time spent performing any other
service you may request of me. If you become involved in legal proceedings that
require my participation, you will be expected to pay for all of my professional
time, including preparation and transportation costs, even if I am called to
testify by another party. [Because of the difficulty of legal involvement, I
charge $300 per hour for preparation and attendance at any legal proceeding.
Also, should I require legal counsel myself, I will ask that you compensate that
attorney as well.]
Due to my
work schedule, I am often not immediately available by telephone. While I am
usually available between 9 AM and 5 PM, I probably will not answer the phone
when I am with a patient. I do have call-in hours at 5- 8 pm on Mondays.
When I am unavailable, my home telephone (508 376-8104) is answered by voice
mail, which I monitor frequently throughout the day. You may also call me at the
office (781 235-0009), but as that is more for new clients, I check that less
frequently. I will make every effort to return your call on the same day you
make it, with the exception of weekends and holidays. If you are difficult to
reach, please inform me of some times when you will be available.
You can always call me at my home number. If you are unable to reach me
and feel that you can’t wait for me to return your call, contact your family
physician or the nearest emergency room and ask for the psychologist
[psychiatrist] on call. If I will be unavailable for an extended time, I will
provide you with the name of a colleague to contact, if necessary.
The law protects the privacy of all communications between a patient and
a psychologist. In most situations,
I 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 other situations that require only that you provide written,
advance consent. Your signature on
this Agreement provides consent for those activities, as follows:
There are some situations where I am permitted or required to
disclose information without either your consent or Authorization:
If a government agency is requesting the information for health
oversight activities, I may be required to provide it for them.
If a patient files a complaint or lawsuit against me, I may
disclose relevant information regarding that patient in order to defend myself
· If a patient files a worker’s compensation claim, I must, upon appropriate request, provide appropriate information, including a copy of the patient’s record, to the patient’s employer, the insurer or the Department of Worker’s Compensation.
There are some situations in which I am legally obligated to take actions, which I believe are necessary to attempt to protect others from harm and I may have to reveal some information about a patient’s treatment. These situations are unusual in my practice.
If I have reasonable cause to believe that a child under age 18 is
suffering physical or emotional injury resulting from abuse inflicted upon him
or her which causes harm or substantial risk of harm to the child's health or
welfare (including sexual abuse), or from neglect (including malnutrition), the
law requires that I file a report with the Department of Social Services. Once
such a report is filed, I may be required to provide additional information.
§ If I have reason to believe an elderly or handicapped individual is suffering from abuse, the law requires that I report to the Department of Elder Affairs. Once such a report is filed, I may be required to provide additional information.
If a patient communicates an immediate threat of serious physical
harm to an identifiable victim or if a patient has a history of violence and the
apparent intent and ability to carry out the threat, I may be required to take
protective actions. These actions may includ
notifying the potential victim, contacting the police, and/or
seeking hospitalization for the patient
§ If a patient threatens to harm himself/herself, I may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.
If such a situation arises, I will make every effort to fully discuss it with you before taking any action and I will limit my disclosure to what is necessary.
this written summary of exceptions to confidentiality should prove helpful in
informing you about potential problems, it is important that we discuss any
questions or concerns that you may have now or in the future. The laws governing
confidentiality can be quite complex, and I am not an attorney. In situations
where specific advice is required, formal legal advice may be needed.
should be aware that, pursuant to HIPAA, I keep Protected Health Information
about you in two sets of professional records. One set constitutes your Clinical
Record. It includes information about your reasons for seeking therapy, a
description of the ways in which your problem impacts on 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 I receive from other providers, reports of any
professional consultations, your billing records, and any reports that have been
sent to anyone, including reports to your insurance carrier.
examine and/or receive a copy of your Clinical Record if you request it in
writing unless I believe that access would endanger you. In those situations,
you have a right to a summary and to have your record sent to another mental
health provider or your attorney. Because these are professional records, they
can be misinterpreted and/or upsetting to untrained readers. For this reason, I
recommend that you initially review them in my presence, or have them forwarded
In addition, I also keep a set of Psychotherapy Notes. In my case, these are very miminal, as these notes are for me to remind me of issues or treatment plans. These Notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal. You may examine and/or receive a copy of your Psychotherapy Notes unless I determine that it would adversely affect your well-being, in which case you have a right to a summary and to have your record sent to another mental health provider or your attorney.
RIGHTS: HIPAA provides you with several new or expanded rights with regard to
your Clinical Record and disclosures of protected health information. These
rights include requesting that I amend your record; requesting restrictions on
what information from your
Record is disclosed to others; requesting an accounting of most disclosures of
protected health information that you have neither consented to nor authorized;
determining the location to which protected information disclosures are sent;
having any complaints you make about my policies and procedures recorded in your
records; and the right to a paper copy of this Agreement, the attached Notice
form, and my privacy policies and procedures. I am happy to discuss any of these
rights with you.
Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records, unless I believe this review would be harmful to the patient and his/her treatment. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes my policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, I will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. I will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parents any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.
be expected to pay for each session at the time it is held, unless we agree
otherwise or unless you have insurance coverage that requires another
arrangement. Payment schedules for other professional services will be agreed to
when they are requested.
account has not been paid for more than 60 days and arrangements for payment
have not been agreed upon, I have the option of using legal means to secure the
payment. This may involve hiring a collection agency or going through small
claims court which will require me to disclose otherwise confidential
information. In most collection situations, the only information I release
regarding a patient’s treatment is his/her name, the nature of services
provided, and the amount due. [If
such legal action is necessary, its costs will be included in the claim.]
for us to set realistic treatment goals and priorities, it is important to
evaluate what resources you have available to pay for your treatment. If you
have a health insurance policy, it
You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, I will provide you with whatever information I can based on my experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, I will be willing to call the company on your behalf.
the rising costs of health care, insurance benefits have increasingly become
more complex. It is sometimes difficult to determine exactly how much mental
health coverage is available. “Managed Health Care” plans such as HMOs and
PPOs often require authorization before they provide reimbursement for mental
health services. These plans are often limited to short-term treatment
approaches designed to work out specific problems that interfere with a
person’s usual level of functioning. It may be necessary to seek approval for
more therapy after a certain number of sessions. While much can be accomplished
in short-term therapy, some patients feel that they need more services after
insurance benefits end. [Some managed-care plans will not allow me to
You should also be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. I am required to provide a clinical diagnosis. Sometimes I am required to provide additional clinical information such as treatment plans or summaries, or copies of your entire clinical record. In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, I have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier.
have all of the information about your insurance coverage, we will discuss what
we can expect to accomplish with the benefits that are available and what will
happen if they run out before you feel ready to end your sessions. It is
important to remember that you always have the right to pay for my services
yourself to avoid the problems described above [unless prohibited by contract].
signature below indicates that you have read the information in this document
and agree to abide by its terms during our professional relationship. [If the
Agreement and Notice are given to patients at the end of the first session and
patient is only required to sign the Acknowledgement at the end of the first
session, leaving the Agreement to be signed at the beginning of the second
SIGNATURE BELOW INDICATES THAT YOU HAVE READ THIS AGREEMENT AND AGREE TO ITS
TERMS AND ALSO SERVES AS AN ACKNOWLEDGEMENT THAT YOU HAVE RECEIVED THE HIPAA
NOTICE FORM DESCRIBED ABOVE.] [If
Agreement is sought before treatment or evaluation begins.