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Terms and Policy

POLICIES + CLIENT SERVICE AGREEMENT
LAURA FEDERICO, MS, LCSW

POLICIES + CLIENT SERVICE AGREEMENT

As a Licensed Clinical Social Worker, I am governed by various laws and regulations and by the code of ethics of my profession. The ethics code requires that I make you aware of my specific practice policies and procedures, how these policies and procedures may affect you, and your rights as a client. I welcome any questions you may have about this document and will address them during your intake appointment.

CONFIDENTIALITY OF DISTANCE SUPPORT

The laws that protect the privacy and confidentiality of sensitive information, which may include both the United States Health Insurance Portability and Accountability Act, the Swiss Federal Act on Data Protection, and other applicable federal, state and international laws, also apply to distance support. I contract with a HIPAA-compliant office platform, CounSol, which allows us to communicate through secure and safe written messaging, video and instant message sessions, and keeps sensitive information protected.

We conduct our clinical communication through our CounSol online office, allowing for safe and secure support.

There are risks from teletherapy, including, but not limited to, the possibility, despite reasonable efforts on my part, that: the transmission of sensitive information could be disrupted or distorted by technical failures; the transmission of sensitive information could be interrupted by unauthorized persons; and/or the electronic storage of sensitive information could be accessed by unauthorized persons. You agree that I am not responsible for disruptions or interruptions to our communications.

I ask that you determine who has access to your computer and electronic information prior to our sessions. This would include family members, co-workers, supervisors and friends. I encourage you to only communicate through a computer that you know is safe, i.e. wherein confidentiality can be ensured. Be sure to fully exit all online teletherapy sessions and emails. I encourage you to find a location for our sessions with proper lighting, limited audio and visual distractions, and a sound barrier to prevent others overhearing the session.

If you choose to email me from your personal email account, please limit the contents to basic issues such as cancellation or change in contact information. I will not respond to clinical concerns via regular email. If you want to send personal or clinical information by email then you will need to communicate with me using encrypted and secure messages via CounSol. You are responsible for information security on your computer or device. If you decide to keep copies of our confidential clinical correspondence on your computer or device, it is your responsibility to keep that information secure.

There is the possibility of an interruption in service due to technical difficulties or poor visual quality. In the event that this happens, I will re-initiate the session. If reconnection is not possible, then we will message to reschedule. Please note that CounSol has state of the art HIPAA-compliant security, including:

Servers housed in Tier-IV data center with SSAE16, HITRUST, ISO 27001 & PCI 2.0 compliance
PCI (Payment Card Industry) standards applied to our internal systems and software
All traffic is required to use SSL (Secure Socket Layer) with 256-bit encryption
Unique login for all users
Logging of all user activity
256-bit encryption of all sensitive data
No sensitive information is sent via email, only notifications to login will be sent
Data backed up hourly using 256-bit encryption

Please note that CounSol is located in the United States and that your personal data may be processed in the United States, Switzerland and the European Union, and you agree to such processing. In addition, CounSol uses software tags known as "cookies" within certain functions of its web sites to remember its visitors' preferences and to maximize the performance of the site and the individual's experience. Access to certain functionality may not be available to individuals that do not give their consent to the data processing carried out through cookies or whose browsers are set to reject all cookies.

Teletherapy may not be as complete as face-to-face support. I will tell you if I believe you would be better served by face-to-face services and will refer you to a practitioner who can provide such services if necessary. I do not provide emergency or crisis services within my practice, and will refer you to appropriate services if it seems distance support is not clinically appropriate for you at this time.

PROFESSIONAL RECORDS

The laws and standards of my profession require that I keep Protected Health Information (PHI) about you in your clinical record. Your clinical record may contain information such as a diagnosis, intake information, consent to treatment, treatment plan, phone and email contact, and treatment notes. Treatment notes are brief summaries of our individual sessions outlining important issues, facts, or any treatment recommendations discussed. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may request in writing to examine and/or receive a copy of your clinical record. These are professional records that can be misinterpreted and/or upsetting to untrained readers. For this reason, I strongly recommend that you review them in my presence or upon your written consent, have them sent to another mental health professional to review with you. For more information regarding how I can use and disclose your PHI, please refer to my Notice of Privacy Practices.

FEES + PAYMENT FOR SERVICES

My current full fee for a monthly teletherapy plan is $350. This includes 4 standard sessions of 45 minutes as well as written communication between sessions pertaining to client care plan. The scope of written communication is determined by me after careful consideration of best client care. My current fee for a pay-as-you-go standard teletherapy session of 45 minutes is $125, for an extended 60-minute session the fee is $150. If a true hardship exists, I will take such matters into consideration. If finances prohibit us from continuing to work together, I will do my best to direct you towards a referral better suited to your needs. Fees are to be paid at time of service through my confidential website. You will be notified in advance in writing if any changes in fees are to be made. Please discuss with me if circumstances prohibit you from paying your bill on a monthly or weekly basis. I am unable to accumulate balances; if your account is more than 60 days past-due and suitable arrangements for payment have not been agreed upon, I have the option of suspending or discontinuing your treatment. I do not participate in any US-based insurance plans at this time.

CONTACT BETWEEN SESSIONS

I do not provide emergency services within my practice. A crisis resource for 24/7 mental health support is 1-800-LIFENET (1-800-543-3638). In the event of a life or limb-threatening emergency, always call 911 or go to the nearest emergency room. To contact me between sessions, I ask that you utilize CounSol's safe and secure messaging platform. I check these messages every 24 hours and will respond accordingly. In the instance I will be unavailable for an extended period of time, I will provide you with a referral in advance.

SESSIONS + CANCELLATION

All sessions will be made in advance by appointment. Other than for true emergencies, it is expected that you will attend your scheduled session. If canceling is necessary, I require a minimum of 24 hours notice; if notice is given under 24 hours, I will charge you my normal fee of $125 per 45-minute session and $150 per extended 60-minute session. If you have a monthly plan, you will be charged $85 per cancelled session. I try to accommodate requests to reschedule when conflicts arise, though it must be within the same week of your appointment time and is subject to my availability.

ENDING SERVICES

You have the right to end services at any time. Should you decide between sessions to withdraw from services, I request that you attend at least one additional teletherapy session to discuss the reasons with me.

GOVERNING LAW

You agree that this Agreement, the rights and obligations hereunder, and any claims or disputes remaining thereto, including, but not limited to, disputes regarding fees and/or malpractice or other tortious or contractual claims, shall be governed by and construed in accordance with the laws of the State of New York without regard to its rules with respect to conflicts of laws. I further understand that in the event of litigation arising from a dispute, the federal and state courts located in the County of New York, State of New York (where I am licensed), and the courts and regulatory agencies and bodies therein, shall serve as the venue for all legal disputes. By entering into the Agreement, you consent to the courts of the State of New York having personal jurisdiction over me for all disputes arising in connection with this Agreement.

I agree to the terms and conditions contained in this Client Services Agreement. I agree to pay for each scheduled therapy session for the fee established with Laura Federico, MS, LCSW. I understand that I am financially responsible for paying for all scheduled sessions. I agree to provide updated credit card information to be kept on file to cover the cost of scheduled sessions that I did not show up for or that I did not cancel with at least 24 hours advance notice. I accept that any missed appointments or late cancellations will result in my credit card being charged the regular fee amount for individual sessions as outlined in this Client Services Agreement.
( Type Full Name )
INFORMED CONSENT FOR DISTANCE SUPPORT
LAURA FEDERICO, MS, LCSW

INFORMED CONSENT FOR DISTANCE SUPPORT

I hereby consent to participating in distance support via the internet (hereinafter referred to as "teletherapy")

I understand that by entering into this agreement (hereafter the "Agreement"), the terms and conditions of which I have reviewed in depth, I provide my informed consent to Laura Federico (hereafter the "Treating Therapist") such that I will participate in teletherapy with the treating therapist in accordance with the terms of this Agreement.

I understand that "teletherapy" allows my treating therapist to consult, treat, transfer sensitive data, and educate using interactive audio, video, or data communication regarding my treatment.

I understand that I have the following rights under this Agreement: I have a right to confidentiality with teletherapy under the same laws that protect the confidentiality of my sensitive information for in- person psychotherapy. Any information disclosed by me during the course of my therapy, therefore, is generally confidential.

There are, by law, exceptions to confidentiality, including mandatory reporting of child, elder, and dependent adult abuse and any threats of violence I may make towards a reasonably identifiable person. I also understand that if I am in such mental or emotional condition to be a danger to myself or others, my treating therapist has the right to break confidentiality in attempts to prevent the threatened danger.

I understand that while psychotherapeutic treatment of all kinds has been found to be effective in treating a wide range of mental disorders, personal, and relational issues, there is no guarantee that all treatment of all clients will be effective. Thus I understand that while I may benefit from teletherapy, results cannot be guaranteed or assured.

I further understand that there are risks unique and specific to teletherapy, including, but not limited to, the possibility that our therapy sessions or other communication by my treating therapist to others regarding my treatment could be disrupted or distorted by technical failures or could be interrupted or could be accessed by unauthorized persons. In addition, I understand that teletherapy treatment is different from in-person therapy and that teletherapy may not be as complete as face-to-face support. If my treating therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.

I understand that I have a right to access my medical information and copies of medical records in accordance with applicable law.

I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment and without risking the loss or withdrawal of any benefits to which I would otherwise be entitled.

Governing Law. I understand that the Treating Therapist is licensed to practice therapy in the State of New York, United States of America. As such, I understand that this Agreement, the rights and obligations hereunder, and any claims or disputes remaining thereto, including, but not limited to, disputes regarding fees and/or malpractice or other tortious or contractual claims, shall be governed by and construed in accordance with the laws of the State of New York without regard to its rules with respect to conflicts of law. I further understand that in the event of litigation arising from a dispute with the Treating Therapist, the federal and state courts located in the County of New York, State of New York, where the Treating Therapist is licensed, and the courts and regulatory agencies and bodies therein, shall serve as the venue for all legal disputes. By entering into the Agreement, I thus consent to the courts of the State of New York having personal jurisdiction over me for all disputes arising in connection with this Agreement.

I have read and understand the information provided above. I have the right to discuss any and all of this information with my treating therapist and to have any questions I may have regarding my treatment answered to my satisfaction.

I acknowledge that I have read and understand the Informed Consent for Distance Support, which is available above. By marking below and submitting this form, I acknowledge that I have read and understand the information provided in such Consent and that any of my questions with respect to such Consent and my treatment have been answered to my satisfaction.
( Type Full Name )
NOTICE OF PRIVACY PRACTICES
LAURA FEDERICO, MS, LCSW

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I am required by law to maintain the privacy of your protected health information and to provide you with this Notice of Privacy Practices (“Notice”) of my legal duties and privacy practices with respect to your protected health information.

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides privacy protection with regard to the use and disclosure of your clinical records (also known as your Protected Health Information or PHI) for the purposes of treatment, payment, and health care operations. This describes the ways in which I may use and disclose your PHI. It also describes your rights and my legal obligations with respect to your PHI.

I reserve the right to change the privacy policies and practices described in this Notice. Unless I notify you by mail of changes, I am required to abide by the terms in this Notice.

EXPLANATION OF USES AND DISCLOSURES:

1. For treatment: I may use and disclose your PHI to provide you with treatment and related services. For example, in order to provide the best possible clinical care for my clients, I may seek professional consultation, such as with your physician. Any other professional with whom I discuss clinical information with is also legally bound to keep the information confidential.

2. For Payment: I may use and disclose your PHI to bill and receive payment for the treatment and services I provide. For example, I may inform your insurance company upon your request to obtain the appropriate approvals and/or to confirm coverage for your treatment.

3. For Health Care Operations: I may also use and disclose your PHI as necessary to operate my practice. For example, I may use and disclose your PHI:

• To review and improve the quality of care you receive;

• To my lawyers, consultants, accountants, and other business associates, including, without limitation, my telecommunications provider (currently, CounSol) to allow me to communicate through written messaging, video and instant message sessions;

• To organizations that evaluate, certify or license me;

• If I sell my practice or merge with another health care entity; and

• To send you appointment reminders.

4. Treatment of Couples: In the treatment of couples, both clients must consent to the release of treatment records. When consent is not given, records will only be released with a court order.

5. Treatment of Minors: Clients under 18 years of age who are not emancipated should be aware that the law may allow both parents the right to examine their treatment records. Privacy in psychotherapy is very important to the success of treatment and I will likely ask parents to respect the need for confidentiality in their child’s therapy relationship. Under most circumstances, some parental involvement in a child’s treatment is essential to successful therapy outcomes. When children are age 12 or older, I will request that an agreement be made between my client and parent(s) to share general information about treatment progress and compliance with scheduled appointments. Other communication about what is shared in session between the child and me will require the child’s authorization. An exception to this agreement would be if I feel that the child may be in danger or is a danger to someone else, in which case, parents will be notified of the concern. I will do my best to discuss these kinds of concerns with the child beforehand if this type of disclosure to a parent becomes necessary.

6. Uses and Disclosures Requiring Authorization: With some limited exceptions, I need to obtain your authorization before releasing your Psychotherapy Notes—notes I have made about your conversations during a counseling session, which may be kept separate from the rest of yourrecord. These notes are given a greater degree of protection than other PHI. You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have already released information based on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

I MAY ALSO USE AND DISCLOSE YOUR PHI WITHOUT YOUR AUTHORIZATION IN LIMITED SITUATIONS.

The following are situations in which I may use or disclose your PHI without your written authorization or an opportunity for you to agree or object, as described below.

- As Required by Law: I may disclose your PHI when required to do so by federal, state or local law or other judicial or administrative proceedings.

- Emergencies: If a client threatens to harm herself/himself, I may be obligated to seek hospitalization for her/him, or to contact family members or others who can provide protection. In addition, if a client communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

- Individuals Involved in Your Care or Payment for Your Care: Unless you object, I may disclose PHI about you to a family member, relative, close personal friend or any other person you identify, including clergy, who is involved in your care. These disclosures are limited to information relevant to the person’s involvement in your care or in payment for your care.

- Reporting Victims of Abuse or Neglect: In the event that a client discloses information that provides evidence of current abuse including neglect of a minor child, or a disabled or elderly adult, the law requires that I report this to the appropriate state agency.

- Health Oversight Activities: When authorized by law, I may disclose your PHI to a health oversight agency for activities, such as audits, investigations, inspections, licensure actions or other legal proceedings. A health oversight agency is a state or federal agency that oversees the health care system.

- Judicial and Administrative Proceedings: If a client files a complaint or lawsuit against me, I may disclose relevant information regarding that client in order to defend myself. In addition, I may disclose your PHI in response to a court or an administrative order. In certain circumstances, I also may disclose PHI in response to a subpoena, a discovery request, or any other lawful process by another party involved in the action. I will make a reasonable effort to inform you about the request.

- Law Enforcement: I may disclose your PHI for certain law enforcement purposes, such as: reports required by law; identifying or locating a suspect or missing person, material witness or fugitive; and answering certain requests for information concerning crimes, about the victim of crimes.

- Military and Veterans: If you are a member of the armed forces, I may use and disclose your PHI as required by military command authorities. I may also disclose your PHI to the appropriate foreign military authority if you are a member of a foreign military.

- National Security and Intelligence Activities: I may disclose PHI to authorized federal officials conducting national security, counterintelligence, and intelligence activities authorized by law. I may also disclose your PHI to authorized federal officials, as needed, to provide protection to the President of the United States, other authorized persons, foreign heads of states or to conduct certain special investigations.

- Workers’ Compensation: If I am providing treatment for conditions directly related to worker’s compensation claim, I may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the Chairman may require.

YOUR RIGHTS

You have the following rights regarding your PHI that I maintain:

1. The Right to Access Your PHI: Except under limited circumstances, and upon written request, you have the right to inspect and obtain a copy of your PHI. Under current New York law, I may charge you no more than 75 cents per page, plus first-class postage, if I make a copy of your medical record. To inspect and request a copy of your PHI, you should submit your written request to me. I must respond to your request within 30 days, by either supplying the records or sending a written notification of denial. If you are denied access to your PHI, in some cases you will have the right to request a review of this denial. The review will be performed by a licensed health care professional designated by me, who did not participate in the original decision to deny access.

2. The Right to Request Restrictions: You have the right to request a restriction on the way I use or disclose your PHI for treatment, payment or health care operations. You also have the right to request restrictions on the PHI that I disclose about you to a family member, friend or other person involved in your care or the payment of your care. If you wish to request such a restriction, you should submit your written request to me. You must tell me what information you want restricted, to whom you want the information restricted, and whether you want to limit my use, disclosure or both.

Generally, I am not required to agree to such a restriction. If I do agree to the restriction, I will honor that restriction except as needed to provide you with emergency treatment.

I am required to honor your requested restriction that I withhold PHI from your insurance plan, subject to you paying for the services you do not wish disclosed, and other specific details. If you wish to request such a restriction, please let me know immediately. I will provide you with additional details on how to obtain this restriction. Be advised, Medicaid may not allow you to make this request.

3. The Right to Request Confidential Communications: You have the right to request that I communicate with you concerning your health matters in a certain manner or at a certain location. For example, you can request that I contact you only at a certain phone number or a specific address. You should submit your written request for confidential communications to me. You must tell me how and where you want to be contacted. I will accommodate your reasonable requests, but may deny the request if you are unable to provide me with appropriate methods of contacting you.

4. The Right to Request an Amendment: You have the right to request that I amend medical or billing records, or other PHI maintained by me, for as long as the information is kept by me. Your request must be made in writing and must explain the reasons for the requested amendment. I may deny your request for amendment if the information: was not created by me (unless you prove the creator of the information is no longer available to amend the record); is not part of the records maintained by me; in my opinion, is information that is accurate and complete; and is information to which you do not have a right of access.

I must respond to your request within 60 days of receiving the request. If I agree to the amendment, I will notify you and amend the relevant portions of your medical record. I will also make a reasonable effort to inform business associates and other individuals known to me, or identified by you, as having the PHI being amended.

If I deny your request for amendment, I will give you a written denial notice, including the reasons for the denial and explain to you that you have the right to submit a written statement disagreeing with the denial. Your statement of disagreement will be attached to your medical record. If you should submit a statement of disagreement, I have the right to insert a rebuttal statement into the medical record. I will provide you with a copy of the rebuttal statement. If you do not wish to submit a statement of disagreement, you may request that a copy of the amendment request and a copy of my denial be included with all future disclosures.

Should I deny your request for an amendment, you have the right to pursue a complaint process by contacting the Secretary of Health and Human Services to lodge your complaint.

If you wish to request an amendment, you should submit the request to me in writing.

5. The Right to An Accounting of Disclosures: You have the right to request an accounting of certain disclosures of your PHI. You may request an accounting of disclosures made up to six (6) years before the date of your request. An accounting is a listing of disclosures made by me or by others on my behalf, but does not include: disclosures made for treatment, payment and health care operations; disclosures made directly to you, that you authorized, or those which are made to individuals involved in your care; disclosure made to correctional institutions or law enforcement official about an inmate in custody; disclosure made for national security or intelligence purposes; disclosure of a limited data set; or an incidental disclosure.

You must submit your request for an accounting of disclosures to me in writing. You must state the time period for which you would like the accounting. I must respond to you 60 days after receipt of your request. The accounting will include the disclosure date, the name, address (if known) of the person or entity that received the information, a brief description of the information disclosed, and a brief statement of the purpose of the disclosure. If you request a listing of disclosures more than once within a 12-month period, I will charge you a reasonable fee for the accounting. The first accounting, within a 12-month period, is provided to you at no charge.

6. The Right to a Paper Copy of This Notice: You have the right to obtain a paper copy of this Notice, even if you have agreed to receive this Notice electronically. You may request a copy of this Notice at any time by contacting my office in writing or by phone.

7. Right to Be Notified of a Breach of Unsecured PHI. You have the right to be notified in the event there is a breach of your unsecured PHI. While I never expect this to happen, if it does, I will contact you (usually by mailing a letter, but I might also call you) to explain what happened, and provide you with additional details and I will let you know that who you can call at my office for more information.

8. Right to request restrictions as a self-pay patient. You have the right to restrict certain disclosures of health information to a health plan if you pay for a service in full and out of pocket. If you choose to restrict any information under this circumstance, you must submit your request in writing to laurafedericotherapy@gmail.com.

COMPLAINTS

If you believe I have violated your privacy rights, or you disagree with a decision I made about access to your records, you have the right to file a complaint in writing with me and/or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. You may also contact the New York Professional Misconduct Enforcement System at 1-800-442-8106 or conduct@mail.nysed.gov. I will not retaliate against you for filing a complaint.

By signing and submitting this form, I acknowledge that I have been provided the Notice of Privacy Practices, which is available above and I consent to the collection, use, processing and disclosure of my Protected Health Information (PHI) as specified therein.
( Type Full Name )