INFORMED CONSENT AND SERVICE AGREEMENT . Bend Psychological Services and Education Options

Informed Consent and
HIPAA Notice for Patients & Clients

Michael G. Conner, Psy.D
Bend Psychological Services
965 NE Wiest Way, No. 2, Bend Oregon 97701
Phone (541) 388-5660

Please Read Carefully

You should not consider your communication with us legally protected or confidential until you are told by us that your communication is protected or until you are told that you are a client or patient.

Please note that we use the word "provider", "us", and "we" to cover all "Services Provided". The words "we" or "us" may mean one or more professionals who may be involved in providing you services. Please let us know if you have any questions before you sign or agree to the terms of this document.

Informed consent and HIPAA Notice For Dr. Michael G. Conner

This document contains information so that you can understand your rights and responsibilities. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA),

Treatment Information

Services Provided. Services provided include therapeutic assessments, psychological evaluations, assessment based interventions, crisis intervention, counseling, psychotherapy and client education. No service will be provided without your consent.

Treatment is Optional and Not Required. Counseling, psychotherapy and crisis intervention services are not required. We do not work with people who are forced to seek treatment by others. You are free to limit or end treatment at any time.

Consultation. From time to time we may find it necessary or helpful to consult with other professionals about their work with you. We believe in using a team approach when necessary. We may provide your name to people we consult with. They will be bound by the same laws and ethical standards.

Service Orientation and Approach. Our approach to working with clients and patients is primarily educational and focused on problem solving with psychotherapy and counseling to support specific problems. Therapy and counseling services are intensive and can result in significant stress as you will be asked to change your behavior. We provide information, recommendations and therapeutic environment intended to give our clients meaningful choices.

Methods. Services provided include individual, group, family, couples, marital, crisis and education. The focus of services are primarily educational and interpersonal with some interpretation directed to providing insight. Cognitive, behavioral, interpersonal and humanistic methods are used to guide services. The primary focus is on education and problem solving that leads to actions. We do not use psychoanalytic or psychodynamic approaches.

Unique Approaches. Family and individual services are provided when appropriate on weekends or after hours. Our practice is primarily educational and may be active with patients in a natural environment. For instance, it might be more effective to leave the office in order to face a fear of crowds. It may become necessary or helpful for us attend an Alcoholic's Anonymous meeting with a patient. In some cases we may take patients or groups of patients on walks, go camping, work with them in community service projects, share a meal in his office or invite patients to social events. These activities would only be offered as a means to support consultation, treatment and evaluation goals. All treatment and supportive services are optional. Patients are not required to participate in treatment.

Electronic Transmissions. Your provider may rely on e-mail to keep in touch with you. We believe private (not an employer's) e-mail system is at least as secure as regular mail or the telephone. However, it is harder to tell if an e-mail has been opened. Be cautious, in some cases an employer can monitor, keep copies and open your e-mail. Patients and clients may complete and submit their history and biographical information on-line. This submission method is at least as secure as mail. All electronic records are purged from servers and computers. Hard copies are placed in patient files. As an alternative, you may print any intake forms available on-line and complete it using a pen and mail it, it or bring it to your first appointment. You are not required to use e-mail or complete historical information on-line.

Risk of Life Changes. Therapy, counseling, crisis intervention, consultation and education services may have a profound impact. Our work is very intensive and can be stressful. We will give you the option to proceed slowly or at a more rapid pace. In most cases, there is improvement without unexpected problems. However, it is possible that there may be no change, problems or a disruptive change. For example, couples in conflict may decide to divorce. Children may become resistant to changes that you are making in your approach to parenting. Unexpected changes or results sometimes occur and cannot be predicted.
Consent of Minors. We do not offer or provide services to minors without the permission of both parents, court or the legal guardian. Minors who are 14 or older can seek treatment without parental consent. It is our policy to work with children only when the parents are involved. We will not work with minors who object to our work with their parents as well. Patients under 14 years of age who are not emancipated and their parents should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, for children between 14 and 18, it is sometimes our 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, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We 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 we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of his concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do his best to handle any objections he/she may have.
Legal Issues. We will not provide legal advice or forensic services as part of treatment. We may bring up issues for you consider, but we recommend you seek legal opinions. Without mutual agreement, and a contract for services, we generally do not provide assessments or recommendations in support of legal actions such as child custody, competency evaluations, law suites or criminal charges. Please notify your us immediately if you are involved or may become involved in a legal or criminal matter.
Contacting Your Provider. Due to our work schedule, we may not immediately available by telephone. While we are usually in our office between 8 AM and 5 PM, we probably will not answer the phone when we are with a patient. When we are not unavailable, our telephone is answered by an answering machine that we monitor frequently. We will make every effort to return your call on the same day you make it. If you are difficult to reach, please inform us of some times when you will be available. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the for assistance regarding a mental health emergency. If we are unavailable for an extended time, we will provide current client with the name of a colleague to contact, if necessary.

Confidentiality

Confidentiality is a legal protection and assurance of your right to privacy to the fullest extent allowable Federal and Oregon State statutes. Psychotherapy, counseling, assessment and associated services that are related to diagnosis, evaluation and treatment services provided by licensed professionals are confidential and protected in accordance with state law pertaining to that license. This means that the patient has legal rights and effective steps he or she can take to keep their records and treatment relationship private. Confidentiality does not apply if you are not our client or patient. Confidentiality does not apply until you are told that you are a client or patient.

HIPAA Notice

Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

"PHI" (Protected Health Information) refers to individually identifiable health information. PHI includes any identifiable health information received or created by this office or myself. "Health information" is information in any form that relates to any past, present, or future health of an individual. Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist. Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage. Health Care Operations are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination. "Use" applies only to activities within our [office, clinic, practice group, etc.] such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you. "Disclosure" applies to activities outside of our [office, clinic, practice group, etc.], such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

We may use or disclose confidential information (including but not limited to PHI) for purposes of treatment, payment, and healthcare operations when your written informed consent is obtained. We 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 specific disclosures. In those instances when we am asked for information for purposes outside of treatment, payment and health care operations, we will obtain an authorization from you before releasing this information. We will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes we have made about our conversation during a private, group, joint, or family counseling session, which we have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) we 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.

III. Patient's Rights and Psychologist's Duties

Patient’s Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications 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, we 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 our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). On your request, we 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’s Duties:

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 policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will post these in our office and mail you a copy if reasonably possible when information is requested from your file.

IV. Questions and Complaints

If you have questions about this notice, disagree with a decision we make about access to your records, or have other concerns about your privacy rights, you may contact Michael Conner, Psychologist at 388-5660. If you believe that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written complaint to Michael Conner, Psy.D at 965 NE Wiest Way, No. 2, Bend Oregon, 97701. You may also send a written complaint to the Secretary of the U.S. 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. We will not retaliate against you for exercising your right to file a complaint.

V. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice when information is requested.

Limits of Confidentiality

The office for Bend Psychological Services is a separate building attached to Dr. Conner's home. There is a separate outside entrance. Dr. Conner's wife, daughter, neighbors and occasional house guests may see you enter through the office front door. The reason for your visit, appointment and name will not be revealed to anyone without your permission. Dr. Conner's wife is an employee and is bound by the same laws regarding confidentiality. People come to the office for a variety of reasons that are not related to treatment or mental health services. The reasons patients or clients visit our office are not revealed to anyone without your permission. Bend Oregon is a small town. It is possible that someone in the area may recognize you.

You should be aware that we practice with other mental health professionals in some cases and that we employ administrative staff. You will notified in that is the case. In most cases, we need to share your protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.

There are some situations where we are permitted or required to disclose information without either your consent or authorization:

If you are involved in a court proceeding and a request is made for information concerning your diagnosis and treatment, such information is protected by the psychologist-patient privilege law. we cannot provide any information without your (or your personal or legal representative’s) written authorization, or a court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information.
If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
If a patient files a complaint or lawsuit against me, we may disclose relevant information regarding that patient in order to defend myself.
If a patient files a worker’s compensation claim, he/she automatically authorizes us to release any information relevant to that claim.
Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in our practice.
If there is a child abuse investigation, the law requires that we turn over our patient’s relevant records to the appropriate governmental agency, usually the local office of the Department of Human Services. Once such a report is filed, we may be required to provide additional information.
If there is an elder abuse or domestic violence investigation, the law requires that we turn over our patient’s relevant records to the appropriate governmental agency, usually the local office of the Department of Human Services. Once such a report is filed, we may be required to provide additional information.
If we believe that a patient presents a clear and substantial risk of imminent, serious harm to another person, we may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.
If we believe that a patient presents a clear and substantial risk of imminent, serious harm to him/her self, we 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, we will make a reasonable effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.

While 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 we are not an attorney. In situations where specific advice is required, formal legal advice may be needed.

Policy Regarding "Multiple Relationships"

Bend Oregon is a small town and we have discovered that many of our local patients may know each other and we may not realize the personal connections and relationships that exit. We have found that some of our patients are involved in organizations, both public and private, and that we may also have a personal, business, volunteer or professional relationship with these organizations. For instance, we are involved with St. Charles Medical Center, Bend Memorial Clinic, the Athletic Club of Bend, City of Bend, US Forest Service, Deschutes County, Toastmasters, local newspaper magazines, the college, several churches and the public school system. This means that we may have a lot in common and that we may have mutual interests and community activities. This also means that you will probably encounter someone you know leaving our office. Many of our patients and others have heard of me, read our articles or seen me on television. This means that you will probably know someone who knows us or knows about us.

We will sometimes use the outdoors to work with families in order order to facilitate communication, teamwork and emotional bonding. We may be very involved with the community and care about the people who live here. We may attend a funeral or marriage of a patient or a member of their family in order to support new beginnings and help other grieve their loss. We may visit a patient if they are hospitalized or restricted to their home because of injury or illness. This means you may see us outside our office with friends, our family, our clients, and our patients. We ask many of our patients to take a walk in the park - especially if the office is uncomfortable or creates anxiety for them.

While we do provide clinical services, we think the best way to understand our practice would be if think of us as a private family or community service. We work with entire families and sometimes extended families. We have also work entire neighborhoods. But we may also treat or work with people who are employed by our employer, such as a medical setting or an airline. This normally involves crisis intervention or traumatic incident services. Or, we may work with people such as the owner of a market, store or even a teacher who may work at a school where we provide other services.

We feel we have an obligation to inform all our patients that there is a strong possibility (almost a certainty) that we may have or will have multiple relationships. You should not work with us as a patient if you do not want us to work with a business that you may have relationship with or you are worried that we might work for your employer some day.

By working with us you understand that we will not pretend that we do not know you. At the same time we will not tell anyone that you are a patient unless you give your permission. We will not reveal the content or purpose of work together without your permission unless we are legally or ethically required. As a general rule we will say "hello" to all our patient. We will acknowledge that we know you. We will refer to you as someone that we know. But since we know many people in town, it is not possible for us to avoid people that you know and we cannot pretend like we do not know someone. We will simply acknowledge that we know you. (To pretend that we do not know you when a another person knows that we do will only identify you as our patient). We are sometimes asked by others if we are treating someone in particular. When asked we will say that we simply know a person and that we would never reveal that kind of information to anyone. We do not talk about or reveal any private information about our patients unless they tell us it is OK. It is up to you to let others know the full extent of our relationship. We are perfectly fine if you wish to keep our relationship private, but at the same time we will not promise that people will not find out that we know you or that you are a patient. You should not work with us as a patient if you are worried that someone might conclude or suspect that you are a patient. You should not work with us as a patient if you want us to pretend that we do not know you.

We hope this has been helpful. Please talk with us about any concerns that you have.

AS A PATIENT, YOU AGREE TO THE FOLLOWING

That you understand that a multiple relationship may exist or occur.
That your provider's practice, professional and community activities are such that a multiple relationship occur and often exist.
That you understand that you may discuss any multiple relationship with your provider and that you have the option to terminate your relationship with us if a multiple relationship occurs or exists.
That you will not expect or ask your provider to terminate a multiple relationship with another patient, individual or organization if one occurs or exists. (You may terminate if you chose to do so.)
That your provider is free to work with individuals, families and organizations even if you have or may have a relationship with those people or organizations. (This means that you have the option to stop working with your provider at anytime you feel there is a risk of harm or that your provider may not be able to work with you effectively)
That your provider may, at his sole discretion, terminate his relationship with you because of a multiple relationship, without telling you about the relationship or any giving you information about the reason for termination.
That you accept full and complete responsibility for any harm, injury or damages that may occur from a multiple relationship, termination of a relationship or that a relationship occurred.
That you should not work with your provider if the potential problems associated with a multiple relationship are not acceptable to you or if you have a concern that you could be harmed, injured or damaged by a multiple relationship. That by working with your provider you agree to hold your provider blameless for the consequence of a multiple relationship that we were not aware of or cannot terminate.