PSYCHOLOGICAL SERVICES AGREEMENT

PSYCHOLOGICAL SERVICES AGREEMENT Jane Allemang, PhD, Clinical Psychologist CLIENT INFORMATION: TODAY S DATE: Name: Date of birth: Age: Sex: Relationship status: (circle) SINGLE MARRIED COHABITING WIDOWED DIVORCED SEPARATED YOUR CONTACT INFORMATION: Street address: City, state, zipcode: (Circle the methods you want me to use when I need to contact you): E-mail address: Home phone #: Cell phone #: Work phone #: (Use email and phone to communicate with me / I do not use text-messaging ) EMERGENCY CONTACT: I authorize Jane Allemang, Ph.D. to disclose my personal information to: Name: Relationship: FINANCIAL RESPONSIBILITY: Name of person responsible for paying co-pays, deductibles, and for other fees: (Stop here if you will not use insurance & you plan to self pay) HEALTH INSURANCE COVERAGE: Primary insurance company name: Insurance ID #: Insurance group#: Secondary insurance company name: Insurance ID #: Insurance group#: DIAGNOSTIC CODE: DSM-V # (Assigned by me/required for filing insurance claims) EAP BENEFITS: If you are using your Employee Assistance Plan: What is the name of the EAP Company?: How many sessions are authorized? What is the Authorization Number?

PRACTICE INFORMATION WELCOME Welcome to my Practice! This form will help you become familiar with how I work. Your clear understanding and consent with these policies is vital to our professional relationship. This form also includes summary information of the Health Insurance Portability and Accountability Act (HIPPA). A full listing of the HIPPA Guidelines is on the wall in the waiting room. If you have any questions, please discuss them with me. BENEFITS AND RISKS OF PSYCHOTHERAPY AND ASSESSMENT Psychotherapy often involves discussing unpleasant aspects of your life. Thus, you may experience uncomfortable emotions, such as sadness, guilt, anger, or frustration. On the other hand, psychotherapy has been proven to lead to better relationships, solutions to specific problems, and significant reductions in feelings of distress. There is no guarantee about what you will experience with me. Success in therapy is based on your motivation and participation, and I encourage you to talk with me if you feel our sessions are not helpful to you. Psychological assessment involves discussing many aspects of your social, emotional, family, academic and occupational functioning. Thus, you might experience similar uncomfortable emotions as in psychotherapy. Outcomes of psychological assessment will be based on the information received (from you and/or others. I do not administer formal assessment measures. If you should have any questions regarding the assessment process or require additional information, please discuss them with me. FEES Initial Psychotherapy Assessment Session (60 minutes) $160 Individual Psychotherapy Session (45 minutes) $140 Family or Couples Sessions (45 minutes) $150 No show or Late cancellation One-session Assessment Consultation - without report (60 minutes) $180 Single-page Letter Writing (per page) $140 Phone calls over 5 minutes (prorated) $30/10 minutes PAYMENT Payment of session fees, deductibles, and/or co-pays is due at each session. I will bill your insurance company, but it is your responsibility to follow up with the insurance company if problems occur. As a rule you are responsible for all fees incurred and for any fees not paid by your insurance provider. Your insurance company may not cover some charges; for example, co-payments, deductibles, out-of pocket expenses, specified noncovered charges as in some types of assessment like psycho educational evaluations, etc. These charges should be paid at the time of service by cash, check, Visa or MasterCard. Some insurance companies require that you have prior authorization to see me. You are responsible for obtaining any initial authorization. Review your membership materials to verify your benefits and coverage and determine what deductibles will apply, if any. You should make sure that I am a participating provider for your plan; if not, you may consider accessing out-of-network benefits or pay out of pocket for the services. Self-Pay: You may choose to be a self-pay client. If you do so, I will not bill an insurance company and I will expect full payment from you when services are provided, unless other arrangements are made. This is an agreement between you and me. EAP: If you are referred from an EAP program you will likely not have any fees associated with service. Your EAP benefits will explain the fees, if any, associated with this service. EAP services are usually limited to a specified number of sessions which is given when the authorization is received. APPOINTMENTS AND CANCELLATIONS You will be charged $50.00, not billable to insurance, if you cancel without 24 hour notice or fail to show up for a scheduled appointment. The exception is when we both agree that you were unable to attend due to your illness or that of a family member, or for some other reason we both deem sufficient.

Please use voicemail or email to leave messages regarding cancellations and rescheduling. Be aware that no communication method offers complete confidentiality. If for any reason you chose to discontinue our sessions please do me a courtesy by letting me know of your decision. Psychotherapy is meant to help you reach your goals, and if it is no longer working for you, you should discontinue sessions. If the reason you wish to discontinue is the cost, perhaps we can work out some other payment arrangement. Payment for cancellations is due at the next session. Late cancellations or missed appointments for EAP service will be recorded as a session per EAP policies and may not be part of your plan. OFFICE HOURS AND EMERGENCIES My office hours are Monday, Tuesday, and Wednesday. I will return calls during these times. If you need to speak to me outside of these hours, and it is a life-threatening emergency associated with our work together, you may call me at any time. If for any reason you cannot reach me, call 911 or go to the nearest emergency room. CONFIDENTIALITY AND EXEMPTIONS TO CONFIDENTIALITY Your records are confidential and will not be sent or shown to others without a signed release from you. You may receive a copy of your signed authorization and request a copy of it. I make reasonable efforts to limit the information shared to the minimum necessary to accomplish the intended purpose of the disclosure. In such instances, I make every effort to discuss this with you. However, there are some exceptions of which you need to be aware. RECORDS By using your insurance, you have consented for me to release information to your insurance carrier and any billing service I may use. Your signature on this document authorizes me to release information to your insurance company for the length of your treatment and until all fees have been paid. Consultations with a colleague do not require your authorization, as any consultant is also bound by the same HIPPA Privacy Policy. I would not share information that could be used to identify you. If your balance goes unpaid and arrangements have not been made for payment, I have the option of using legal means to secure the payment, such as hiring a collecting agency or going through small claims court. Both of these actions would require me to disclose otherwise confidential information, including your name, that psychotherapy sessions were provided, and the amount due. If a court is used, its costs will be included in the claim. I may also disclose your private health information without consent if I have reasonable cause to suspect that a child under age 18 or a mentally or physically handicapped person faced a threat of suffering any physical or mental wound, injury, disability, or condition that reasonably indicated abuse or neglect. I am required by law to disclose such information. If I believe that you pose a clear and substantial risk of serious imminent harm to yourself or another person, I may disclose your relevant information to public authorities, the potential victim, other professionals, and/or your family to protect against such harm. If I believe that I cannot effectively and ethically treat you without collaborating with another professional (ie. primary care doctor or specialist) I may refer you to another psychotherapist in the event that I do not receive your consent. If I come to believe that I can no longer treat you effectively or ethically I will discuss this with you and I may refer you to another psychotherapist. Your clinical record consists of your reasons for seeking therapy, diagnoses, goals, medical and social history, treatment history, copies of other records, reports, and billing records. Psychotherapy notes are for my use and are designed to assist me in providing you with the best treatment. These notes often include the contents of our conversation, analysis of therapy, and other sensitive information. These notes, if developed, are kept separate from your clinical record to protect their confidentiality from insurance company audits. While psychotherapy notes have stronger restrictions than your clinical record, authorization is not required for their release in the following situations: for my own use, to defend myself against legal action, for purposes of the Department of Health and Human Services in determining my compliance with HIPPA policy, and/or the

exceptions that are listed in the OHIO NOTICE FORM (on the wall of my waiting room and on the following 2 pages). You have the right to request to see or receive a copy of your entire clinical record or psychotherapy notes. OTHER POLICIES HIPPA requires that I inform you of policies and your rights in several other areas. Restrictions and Confidential Communications, Access to and Amendment of Records, Accounting for Disclosures, Business Associates, Privacy Officer, Safeguards, Complaints, Retaliatory Action and Waiver of Rights, and Documentation. Information on all of these is printed in the OHIO NOTICE FORM. CONSENT FOR TREATMENT Your signature indicates that you have read this agreement and consent to the policies outlined here. Client/Guardian Signature: Date: Printed Name:

OHIO NOTICE FORM: HIPAA (NEXT TWO PAGES) HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT 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 and keep it for future reference. According to federal law I must provide you with this information which describes how psychological and medical information about you may be used and disclosed. Please read about these policies and practices and consider the impact they may have on your life. USES AND DISCLOSURES FOR TREATMENT, PAYMENT, & HEALTH CARE OPERATIONS I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. Here are definitions of these terms: PHI refers to information in your health record that could identify you. It includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Treatment is when I provide, coordinate or manage your health care and other services related to your care. An example would be when I consult with another health care provider, such as your family physician or specialist. Payment is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for my services to you or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of this are quality assessment and improvement activities, business-related matters (such as audits and administrative services), case management, and care coordination. Use applies only to activities within my practice, such as sharing applying, utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside of my practice, such as releasing, transferring, or providing access to information about you to other parties. USES AND DISCLOSURES REQUIRING AUTHORIZATION I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An authorization is written permission, above and beyond the general consent that permits only specified disclosures. In these instances when I am asked for information, I will obtain a written authorization from you before releasing this information. I will also need to obtain an authorization before releasing psychotherapy notes. Psychotherapy notes are notes I have made about our conversation during an individual, group, joint, or family counseling session, which I have kept separate from the rest of your record according to law. These notes are given more protection than PHI. You may revoke all such authorizations (for PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied 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. If you file a worker s compensation claim, I may be required to give your mental health information to relevant parties and officials USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION I may use or disclose PHI without your consent or authorization in the following circumstances: Adult and Domestic Abuse: If I have reasonable cause to believe that an adult is being abused, neglected, or exploited, or is in a condition which is the result of abuse, neglect, or exploitation, I am required by law to immediately report such belief to the County Department of Job and Family Services. Judicial or Administrative Proceeding: If you are involved in a court proceeding and a request is made for information about your evaluation, diagnosis, and treatment and the records thereof, such information is privileged under state law and I will not release this information without written authorization from you or your persona or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. You would be informed in advance if this was the case. Serious Threat to Health or Safety: If I believe that you pose a clear and substantial risk of imminent serious harm to yourself or another person, I may disclose your relevant confidential information to public authorities, the potential victim, other professionals, and /or your family in order to protect against such harm. If you communicate to me an explicit threat of inflicting imminent and serious physical harm or causing the death of one or more clearly

identifiable victims, and I believe you have the intent and ability to carry out the threat, then I am required by law to take one or more of the following actions in a timely manner: Take steps to hospitalize you on an emergency basis Establish and undertake a treatment plan calculated to eliminate the possibility that you will carry out the threat, and initiate arrangements for a second opinion risk assessment with another mental health professional. Communicate to a law enforcement agency and, if feasible, to the potential victim(s), or victim s parent or guardian if a minor, all of the following information the nature of the threat, your identity, and the identity of the potential victim(s). PATIENT RIGHTS Right to Request Restrictions: You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction at your request Right to Receive Confidential Communications by Alternative Means and at Alternative Locations: You have the right to request and receive confidential communication of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address. Right to Inspect and Copy: You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Right to Amend: You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. On your request I will discuss with you the details of the amendment process. I may accept or deny your request. Right to an Accounting: You generally have the right to receive an accounting of disclosures of PHI for which you have not provided either consent or authorization (as described in Section III of this Notice). On your request, I will discuss with you the details of the accounting process. Right to a Paper Copy: You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically. PSYCHOLOGIST DUTIES I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect. If I revise my policies and procedures, I will, if these changes affect your PHI, send notice of these changes to you by regular mail at your last known address to me. QUESTIONS AND COMPLAINTS If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may contact me at Jane Allemang, Ph.D., 7577 Central Parke Blvd, Ste 112, Mason, OH 45040, 513-399-7070. If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to Jane Allemang, Ph.D., 7577 Central Parke Blvd, Ste 112, Mason, OH 45040, 513-399-7070. You may also send a written complaint to the Secretary of the US Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. I will not retaliate against your for exercising your right to file a complaint. EFFECTIVE DATE - This notice went into effect on April 13, 2003 RESTRICTIONS I will limit the uses or disclosures that I will make as follows: to comply with current laws. RIGHT TO CHANGE TERMS I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by regular mail at your last known address I noted in my files.

ACKNOWLEDGEMENT OF RECEIPT OF THE OHIO NOTICE FORM AND HIPAA POLICIES (PREVIOUS 2 PAGES) Your signature indicates that you have received or read the OHIO NOTICE FORM and HIPAA policies discussed in this document: Client/Guardian Signature: Date: Printed Name: