Practice Policies

INFORMED CONSENT FOR PSYCHOTHERAPY TREATMENT

I am pleased to have the opportunity to work with you, explore your concerns, hopes and values. I hope to help you get a clearer understanding of the problems that got you to seek out therapy and the narratives that are present that support those problems. I am excited to learn more about you, the way you prefer to live your life, what you find important in life and the knowledges you already have that can help you move closer to your preferred story.

Therapy is a joint process between you and your therapist. Your opinions concerning this process are vital to its success. Please let me know if you have any concerns about any aspect of therapy or have any questions about the process. If therapy seems to be having negative effects on your life, please inform us so we can seek alternate means for helping.

Mountain View Therapy recognizes the significance of the therapeutic relationship. If for any reason you feel like your assigned clinician is not the best match for you, we are happy to facilitate a smooth transition to another qualified clinician who might be a better fit for you. Please contact our Intake Coordinator at amber@mountainviewtherapyma.com if you do not feel comfortable bringing this up with your therapist.

PRACTICE POLICIES

Appointments
The initial meeting will typically last for 1 hour. In this meeting, we work to listen to your concerns, obtain relevant information and begin to identify some ways we may assist you in addressing your problems. We will begin formulating “treatment goals” for therapy and we will take time to answer any questions you may have. Subsequent meetings are typically 45 to 60 minutes.

Payment for Services:
There are three options for payment of service: In-Network Insurance, Out-of-Network Insurance benefits, or Self-Pay. Please note if you are seeing 2 therapists at the same time, the “identified client” cannot have 2 therapy meetings on the same day. If you do have 2 meetings in one day, you will be charged for the one that the insurance does not cover. By choosing to use your insurance benefits, you are authorizing Mountain View Therapy to use and to disclose member records for purposes of payment and health care operations

            In-Network Insurance Information
            All our clinicians accept Blue Cross Blue Shield, Aetna, Tufts Commercial. Some clinicians are also credentialed with Tufts Public Plans as well as               MBHP (except for the BeHealthy Partnership). Lauren Klingman also accepts Wellsense at this time.

It is your responsibility to confirm insurance benefits and eligibility including telehealth coverage before your first meeting. With an in-network insurance or managed care provider, we will submit the insurance claims directly and accept assignments of benefits. You are responsible for the co-payment, co-insurance or deductible payment at the time of the meeting, however your credit card may not be charged for several days after the meeting occurs. 

Your insurance company will make the final decision as to whether our meetings will be covered or are medically necessary. In all cases, regardless of insurance coverage, you are responsible for payment if your insurance fails to make a payment.

Your attendance at a meeting implies your agreement to pay for services. Insurance does not cover cancellation or no-show fees. Please inform us of any changes in insurance as soon as possible. We do not back-bill for services provided before we were informed of the change in insurance.

Out-of-Network Insurance Information
If you have an insurance plan that we are out-of-network for and you wish to use your Out-of-Network benefits, you will be responsible for payment of the full fee at the time of the appointment, and we will provide you with a superbill to submit to your insurance for reimbursement. It is your responsibility to confirm insurance benefits and eligibility including telehealth coverage before your first meeting.

For LICSW level providers- Fees for professional services are $250 for the initial 1-hour meeting and subsequent 53-60 minute meetings, and $215 for subsequent 45 minute meetings.

For LCSW level providers- Fees for professional services are $150 for the initial 1-hour meeting and any subsequent 53-60 minute meetings, and $115 dollars for subsequent 45-minute meetings. LCSW level providers may not be able to accept Out-of-Network benefits. If you are working with an LCSW level provider, please confirm with your insurance that they will reimburse you for an LCSW clinician who is under the supervision of an LICSW clinician.

Self-Pay and Reduced Fee Information
If you wish to opt out of insurance and self-pay for any reason, you may do so and will need to sign an Insurance-Opt-Out form and a Fee Agreement form. Your credit card will typically be charged within the next few business days.

For LICSW level providers- Self-pay fees for professional services are $250 for the initial 1-hour meetings and subsequent 53-60 minute meetings, and $235 for subsequent 45 minute meetings.
For LCSW level providers- Self-pay fees for professional services are $150 for the initial 1-hour meeting and any subsequent 53-60 minute meetings, and $115 dollars for subsequent 45-minute meetings.

If this fee for service would generate a financial burden, please inquire and we can explore the possibility of a reduced fee.

Self-pay fees are subject to change. You can expect a small increase each year to account for inflation and increased overhead costs, and to better reflect market rates for my credentials, specialty and experience level. We will provide you with notice at least 30 days in advance.

Cancellations
We have a 48 hour cancellation policy. Please remember to cancel or reschedule 48 hours in advance. You will be responsible for the $85 dollar late cancellation/no-show fee if your cancellation provides less than 48 hours notice. When you schedule an appointment, we reserve that time solely for you. A timely cancellation allows us to schedule other clients who may be waiting to meet. I appreciate your understanding and consideration. Please note:

• If you are late for a session, you may lose some of that session time. If you are more than 15 minutes late it may be treated as a no-show and you may reschedule your appointment.

• Cancellation fees cannot be billed to your insurance.

• The only exceptions to the cancellation/no-show fee are medical emergencies.

• After 3 late cancellations or missed appointments, we reserve the right to decrease the frequency of meetings or discontinuing therapy.

Please note, this late cancellation/no-show fee does not apply to clients using Masshealth plans or Tufts Public plans for insurance. After 3 late cancellations or missed appointments, we will discuss decreasing the frequency of meetings or discontinuing therapy.

Additional Fees
If additional reports or meetings not covered by the insurance company are needed, you are responsible for paying Mountain View Therapy for the time it takes to write these reports and/or attend these meetings. Reports that would incur a fee would be for, but not limited to: a disability claim and worker’s compensation. Meetings that would incur a fee are, but not limited to: attending an IEP meeting, speaking with an attorney and testifying at court. If I am needed for court, fees may include time lost for cancelled sessions, time for preparation, travel, or waiting, even if the need for testimony is cancelled.

Telephone conversations, preparation of reports and required discussion with third parties are charged at our hourly rate. If we are required to testify in court you will be charged $300/hour plus travel time and expenses due to the amount of time this takes from the clinic, other clients, and for preparation.

Telephone/Text/Email Communication
If you need to contact your therapist urgently between meetings please leave a message on their voice mail. We are often not immediately available; however, we will attempt to return your call within 24 hours. 

We do not provide crisis intervention; If a true emergency situation arises, please call 988 for mental health crises, or call 911, or go to your local emergency room. Please also notify your therapist of the situation so we can think about how to best support you.

We cannot ensure the confidentiality of communication through phone, email or text message. We may communicate scheduling concerns via email or text but we request that you do not use these methods of communication to discuss therapeutic content or request assistance for emergencies. If you choose to communicate protected health information via phone call, email or text, it will indicate that you accept the possible risks associated with such communication.

If you contact us in any manner with a message that indicates a possible emergency or life-threatening situation, you and/or your guardian reserve us the right to make a professional judgment to reach out to the appropriate emergency services or your emergency contact person. Your signature confirms that you trust our professional judgment in case of a medical or mental health emergency and that we will not be held liable when sharing the information to emergency services or your emergency contact person.

Social Media Policy
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. If you have questions about this, please bring them up when we meet and we can talk more about it.

Interactions Outside of Therapy
If we happen to see you outside of therapy, we will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance, and we do not wish to jeopardize your privacy. However, if you acknowledge us first, we will be more than happy to speak briefly with you, but not regarding clinical topics.

Partners/Couples Confidentiality
In the course of couples or partners therapy, there may be occasions when your therapist will meet with each of you individually. Our commitment to transparency means that we will not conceal the occurrence of individual sessions; however, please be assured that the content of these individual meetings will be kept confidential to the fullest extent permitted by legal and ethical standards.

Minors
Mountain View Therapy requires 2 parents/guardians consent for therapy services for individuals under 18 years old. If there are two parents/guardians, both must complete consent forms before the first meeting. If only one person has legal/medical custody, we require the custody agreement to be uploaded to the client’s chart. If you have questions or concerns about this policy please reach out to christina@mountainviewtherapyma.com.

Therapy meetings with minors are typically confidential, with the exception of situations where there is a concern for your safety or the safety of others. Parents/guardians may want to have some information about therapy meetings, and the minor and the therapist will discuss together what information is appropriate to share and what is more appropriate to be kept confidential.

Telehealth
Mountain View Therapy is a virtual practice and we use the HIPAA compliant telehealth platform Simple Practice. There will be no recording of meetings by either party unless consented to. Meetings cannot be conducted if you are driving, intoxicated or inappropriately dressed.

Potential risks include but are not limited to disruption of transmission by technology failures, interruption and/or breaches of confidentiality by unauthorized persons, and my limited ability to respond to emergencies. If we get disconnected please exit and enter the virtual meeting again. If there continues to be a problem, I will call/text you to determine next steps.

State law requires that you be physically located in a state where your provider is licensed during a meeting. You must provide your exact address (in Massachusetts, or for Bailey Schendell’s clients- Massachusetts or Florida) at the beginning of each meeting for documentation.

If you are experiencing suicidal or homicidal thoughts, actively experiencing psychotic symptoms or experiencing a mental health crisis that cannot be resolved remotely, it may be determined that telehealth is not an appropriate medium and a higher level of care may be required. In the event that it is determined telehealth is not an appropriate medium for therapy, you will be referred to another provider who can meet with you face-to-face, which may include emergency services.

Emergency Contact
You must have an emergency contact person on file in case of a life-threatening emergency. If you do not provide an emergency contact, 911 will be used for your emergency contact.

Records

Standards of profession require that I maintain appropriate records of our work together, and these records will be maintained indefinitely. You have the right to these records at your request.

PRIVACY PRACTICES AND PATIENT'S RIGHTS

Your health record contains personal information about you and your health.  This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information (“PHI”). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act (“HIPAA”), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules, the NASW Code of Ethics and Massachusetts statutes and regulations.  It also describes your rights regarding how you may gain access to and control your PHI.

We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices.  We reserve the right to change the terms of our Notice of Privacy Practices at any time.  Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by email, sending a copy to you in the mail upon request or providing one to you at your next appointment.

The rules of confidentiality are complicated and governed by numerous statutes and regulations. If you have any questions, it is your right and obligation to ask for further clarification before you sign this document. If you have any additional concerns regarding your rights, it is best to seek legal counsel from an attorney in advance of undertaking the therapeutic process.

I.  USES AND DISCLOSURES FOR TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS, REQUIRING CONSENT

We may use or disclose your PHI for treatment, payment and health care operations purposes with your consent as discussed below:

For Treatment.  Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members.  An example of treatment would be when we consult with another health care provider, such as a family physician or another social worker for peer consultation when necessary and appropriate. We will attempt to protect your identifying information to preserve confidentiality, but we will seek consultation under our discretion without obtaining informed consent. We may disclose PHI to any other consultant only with your authorization.

For Payment.  We may use and disclose PHI so that we can receive payment for the treatment services provided to you.  This will only be done with your consent. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.  If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

For Health Care Operations.  We may use or disclose, as needed, your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (e.g., billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHI.

II.  USES AND DISCLOSURES REQUIRING AUTHORIZATION

Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked at any time, except to the extent that we have already made a use or disclosure based upon your authorization.  The following uses and disclosures will be made only with your written authorization:

• to speak with outside providers, people in your care team

• most uses and disclosures of PHI for marketing purposes

• disclosures that constitute a sale of PHI

• For training or teaching purposes

• For disclosure or psychotherapy notes which are different from your progress notes and separate from your health record

• other uses and disclosures not described in this Notice of Privacy Practices.

III.  USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION

We may use or disclose PHI without your consent or authorization in the following circumstances:

Serious Threat to Your own Health or Safety: If you present a clear and present danger to yourself and refuse to accept further appropriate treatment, and I have a reasonable basis to believe that you can be committed to a hospital, I must seek said commitment and may contact members of your family, a crisis intervention team or other individuals if it would assist in protecting you.

Serious Threat to others (Duty to Warn): If you communicate to me an explicit threat to kill or inflict serious bodily injury upon an identified person and you have the apparent intent and ability to carry out the threat, I must take reasonable precautions.  Reasonable precautions may include warning the potential victim, notifying law enforcement, or arranging for your hospitalization.  I must also do so if I know you have a history of physical violence and I believe there is a clear and present danger that you will attempt to kill or inflict bodily injury upon an identified person.

Child Abuse: If we, in our professional capacity, have reasonable cause to believe that a minor child 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, we must immediately report such condition to the Massachusetts Department of Children and Families.

Elder Abuse: If we have reasonable cause to believe that an elderly person (age 60 or older) is suffering from or has died as a result of abuse, we must immediately make a report to the Massachusetts Department of Elder Affairs.

Abuse of a Disabled Person: If we have reasonable cause to suspect abuse of an adult (ages 18-59) with mental or physical disabilities, we must immediately make a report to the Massachusetts Disabled Persons Protection Commission.

Health Oversight: The Board of Registration of Social Workers has the power, when necessary, to subpoena relevant records should we be the focus of an inquiry.

Judicial or Administrative Proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and we will not release information without written authorization from you or your legally-appointed representative, or a court order.  The privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case. I can also disclose PHI in the event that I need to defend myself in legal proceedings if you call action against me in a lawsuit.

Worker’s Compensation: If you file a workers’ compensation claim, your records relevant to that claim will not be confidential to entities such as your employer, the insurer and the Division of Worker’s Compensation.

Specialized Government Functions:  We may review requests from U.S. military command authorities if you have served as a member of the armed forces, authorized officials for national security and intelligence reasons and to the Department of State for medical suitability determinations, and disclose your PHI based on your written consent, mandatory disclosure laws and the need to prevent serious harm.

Public Health:  If required, we may use or disclose your PHI for mandatory public health activities to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, or if directed by a public health authority, to a government agency that is collaborating with that public health authority.

Medical Referrals

Coroners, medical examiners or funeral directors

IV.   YOUR RIGHTS AND OUR OBLIGATIONS

Patient’s Rights:

You have the following rights regarding PHI we maintain about you:

• Right of Access to Inspect and Copy.  You have the right to inspect or obtain a copy (or both) of PHI and progress notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record.  Your access may be denied in certain circumstances, but in some cases, you may be able to have this decision reviewed.  On your request, we will discuss with you the details of the request and denial process.  We may charge a reasonable, cost-based fee for copies.  If your records are maintained electronically, you may also request an electronic copy of your PHI.  You may also request that a copy of your PHI be provided to another person.

• Right to Amend.  If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy.   On your request, we will provide you with details of the amendment process.

• Right to an Accounting of Disclosures.  You have the right to request an accounting of PHI for which you have neither provided authorization nor consent.  On request, we will discuss with you the details of the accounting process.  We may charge you a reasonable fee if you request more than one accounting in any 12-month period.

• Right to Request Restrictions.  You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations.  We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a health care item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

• Right to not disclose PHI to a health plan if you pay out of pocket.

• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations.  You have the right to request that we communicate with you about health matters in a certain way or at a certain location.  We will accommodate reasonable requests.  (For instance, you may not want a family member to know you are seeing us.  Upon your request, we will send your bills to another address.)  We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request.  We will not ask you for an explanation of why you are making the request.

• Breach Notification.  If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.

• Right to a Paper Copy of this Notice.  You have the right to a paper copy of this notice upon request, even if you have agreed to receive the notice electronically.

Our Obligations:

• We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI.

• We reserve the right to change the privacy practices described in this Notice.  Unless we notify you of such changes, however, we are required to comply with the terms currently in effect.

• If we revise our privacy practices, we will provide you with a revised notice by email.

V.  COMPLAINTS

If you believe we have violated your privacy rights or you disagree with a decision we made about access to your records, you may contact our HIPAA Compliance Officer, Christina Peterson, LICSW at 518-435-5116 or christina@mountainviewtherapyma.com. You may also send a written complaint to the Secretary of Health and Human Services at 200 Independence Avenue, S.W.  Washington, D.C. 20201 or by calling (202) 619-0257.  We will not retaliate against you for filing a complaint.

This policy went into effect on March 10, 2021