Insurance: We will take a copy of your insurance. 

I understand that should I, at any time during the course of my treatment, need to cancel or change an appointment time, I will need to do it 24 hours in advance of the appointment time or be charged for the hour, since it has been reserved for me and without sufficient notice is unavailable to another client.

Please note: This is not a charge which can be submitted to insurance.

I understand that although my insurance may pay a portion of the cost of the professional services received in this office; I am ultimately responsible for complete payment of the charges. Because of my responsibility and because I realize that prompt payment allows the office to keep its fees as low as possible, I will pay by the session or follow another payment plan negotiated with the therapist.

The psychiatric services provided by Walking Together Therapy Associates, P.C. are strictly on a consultation basis and are not to be considered supervision of another therapist’s work.

The undersigned hereby employs Walking Together Therapy Associates, P.C. to render psychological and/or psychiatric counseling services and agrees to the following terms in connection with said employment:

1. To pay the balance due indicated on the monthly statement of my account in full within 30 days following the date of the initial billing.

2. In the event suit is necessary to enforce payment of a delinquent account, the undersigned agrees to pay for attorney’s fees and all court costs incurred therein. Venue for said suit shall be in Cook County, Illinois.

3. In the event that an outside Collections Agency is necessary to enforce payment of a delinquent account, there will be a 9% interest annually charged to said account.

4. There will be a $25 service charge for all returned checks.

5. To examine each monthly statement within 30 days of the billing date and advise Walking Together Therapy Associates, P.C. of any billing errors.

FEES:

Initial Diagnostic Assessment | (45-50 minutes) | 90791 | $204.00

Individual Therapy 45 min | (38-52 minutes) | 90834 | $126.00

Individual Therapy 60 min | (53+ minutes) | 90837 | $183.00

Conjoint/Family Therapy | (45-50 minutes) | 90847 | $153.00

Individual Therapy 30 min | (16-37 minutes) | 90832 | $83.00

Telephone Consultations (45-50 minutes) | $40 per 15 minutes*

Correspondence, letters, reports (i.e. FMLA paperwork, psychological reports, disability reports, letters to attorneys, school, etc.) | Fee determined by therapist at conclusion of report*

*This can include any phone calls made for the purpose of exchanging information and coordinating a client’s care. (i.e. child’s teachers, school counselor, social worker, medical doctor, attorney etc.) Health care companies do not usually consider this a reimbursable expense.*

***All court cases are billed per court ordered fees***

Our patient payment policy is to collect all co-pays, co-insurance, deductibles or self-pay fees at time of service to ensure your account stays up to date. The credit card you are providing will be securely stored within our encrypted and HIPAA compliant third party virtual vault which is available only to our billing department for these charges to be made at time of service.

If at any time your card is declined for lack of funds, expired date, etc., we will notify you immediately to secure a new credit card ensuring no interruptions in payments to your account. You may contact our front office to update your card information at any time.

Introduction

At Walking Together Therapy Associates, P.C., we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your rights as they relate to your protected health information. This notice is effective 9/23/2013, and applies to all protected health information as defined by federal regulations.

Understanding Your Health Record/Information

Each time you visit Walking Together Therapy Associates, P.C., a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information is often referred to as your health or medical record or PHI (Patient Health Information).

Our Privacy Practices

Use and Disclosure: We may use or disclose your PHI for treatment, payment or health care operations. For example:

• Treatment: Your PHI may be used or disclosed to any physicians or other health care providers involved with the medical services provided to you.
• Payment: Your PHI may be used or disclosed in order to collect payment for the medical services provided to you.
• Health Care Operations: Your PHI may be used or disclosed as part of our internal health care operation. Such health care operations may include, among other things, quality of care audits of our staff and affiliates, managed care peer review or Medicaid or Medicare peer review, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Authorization: We will not use or disclose your medical information for any reason except those described in this Notice unless you provide us with a written authorization to do so. We may request such an authorization to use or disclose your PHI for any purpose, but you are not required to give us such authorization as a condition of your treatment. Any written authorization from you may be revoked by you in writing at any time, but such revocation will not affect any prior authorized uses or disclosures.

We will also obtain an authorization from you before using or disclosing:

• PHI in a way that is not described in this Notice.
• Psychotherapy notes.

Patient Access: We will provide you with access to your PHI, as described below in the Individual Rights section of this Notice.

Locating Responsible Parties: Your PHI may be disclosed in order to locate, identify or notify a family member, your personal representative or other person that is responsible for your care. If we determine in our reasonable professional judgment that you are capable of doing so, you will be given the opportunity to consent to or prohibit or restrict the extent or recipients of such disclosure. If we determine that you are unable to provide such consent, we will limit the PHI disclosed to the minimum necessary.

Disasters: We may use or disclose your PHI to any public or private entity authorized by law or by its charter to assist in disaster relief efforts or to avert a serious threat to public health or safety.

Required by Law: We may use or disclose your medical information when we are required to do so by law. This might include information for judicial and administrative proceedings in response to an order of the court or an administrative tribunal; or a subpoena, discovery request or other lawful process, not accompanied by a court order or an ordered administrative tribunal.

Deceased Persons: After your death, we may disclose your PHI to a coroner, medical examiner, funeral director, or organ procurement organization in limited circumstances.

Research: Your PHI may also be used or disclosed for research purposes only in the limited circumstance not requiring your written authorization, such as those that have been approved by an institutional review board that has established procedures for ensuring the privacy of your PHI.

Military and National Security: We may disclose to military authorities the medical information of Armed Forces personnel under certain circumstances. When required by law, we may disclose your PHI for intelligence, counterintelligence and other national security activities.

Uses and Disclosure in Emergency Situations: We will use and disclose PHI as appropriate to provide treatment in emergency situations such as suicide, homicide, child and/or elder abuse. In those instances where we have not previously provided our NPP to a patient who receives direct treatment in an emergency situation, we will provide the Notice as soon as practicable following the provision of the emergency treatment.

When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state's confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

Marketing Purposes: We will not use or disclose any PHI for marketing purposes unless we have your written permission to do so. We may engage in communications about products and services that encourages recipients of the communication to purchase or use the product or service for treatment, to direct or recommend alternative treatments, therapies, healthcare providers or settings of care to the individuals. We may contact the individual with appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to the individual. We may e-mail the above information if we have your permission to do so.

Your Individual Rights

Access and Copies: In most cases, you have the right to review or to purchase copies of your PHI (excluding psychotherapy notes) by requesting access or copies in writing to our Privacy Office. Please contact our Privacy Officer regarding our copying fees.

Disclosure Accounting: You have the right to receive an accounting of the instance, if any, in which your PHI was disclosed for purposes other than those described above for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a twelve-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Requests must be made in writing to our Privacy Officer.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make this request in writing to our Privacy Officer. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Right to Restrict Disclosures When You Have Paid for Your Care Out of Pocket: You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for our services.

Right to be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) our risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Amendment: You have the right to request that we amend your health information. Your request must be in writing and it must explain why the information should be amended. Under certain circumstances we may deny your request but will provide you with a written explanation of the denial. You have a right to send us a statement of disagreement to which we may prepare a rebuttal, a copy of which will be provided to you at no cost. Please contact our Privacy Officer with any further questions about amending you medical record.

We reserve the right to change our practices at any time and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us, or if you agree, we will e-mail the revised notice to you.

For More Information or to Report a Problem or if you have questions and would like additional information, you may contact our Privacy Officer at (847) 310-8578. If you believe your privacy rights have been violated, you can file a complaint with the practice’s Privacy officer or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights.. The address for the OCR is listed below:

Office of Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W. Room 509F, HHH Building
Washington, D.C. 20201