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Terms and Policy

Health Insurance Portability and Accountability Act (HIPAA)
Disclosure & Privacy Notice
Effective Date: September 16, 2013

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review this notice carefully and initial/sign where necessary.

Authentic Self Counseling (henceforth “ASC”) considers personal information to be confidential and protects the privacy of that information in accordance with applicable privacy laws.

ASC is required by law to take reasonable steps to ensure the privacy of your information and to inform you about:
• ASC’s uses and disclosures of your health information
• Your privacy rights with respect to your health information
• ASC’s obligations with respect to your health information
• Your right to file a complaint with the Secretary of the U.S. Department of Health and Human Services

How ASC Uses and Discloses Health Information
This section of the notice describes uses and disclosures that ASC may make of your health information for certain purposes without first obtaining your permission, as well as instances in which we may request your written permission to use or disclose your health information. ACS also requires their business associates to protect the privacy of your health information through written agreements.

Uses and Disclosures Related to Payment, HealthCare Operations, and Treatment
ASC and its business associates may use your health information without your permission to carry out payment.
Payment includes, but is not limited to, actions to make coverage determinations and payment including billing, claims management, subrogation, plan reimbursement, review for medical necessity and appropriateness of care and utilization review and pre-authorizations.

Other Uses and Disclosures That Do Not Require Your Written Authorizations
ASC may disclose your health information to persons and entities that provide services to ASC and assure ASC they will protect the information if it is:
• For judicial and administrative proceedings
• For law enforcement purposes
• For public health activities
• For health oversight activities
• About victims of abuse or neglect
• To avert a serious threat to health or safety

Uses and Disclosures Requiring Your Written Authorization
In all situations other than those described above, ASC will ask for your written authorization before using or disclosing your health information. If you have given ASC an authorization, you may revoke it in writing at any time, if ASC has not already acted on it. If you have questions regarding authorizations, contact ASC.

Your Privacy Rights
This section of the notice describes your rights with respect to your health information and a brief description of how you may exercise these rights. To exercise your rights, you must contact ASC.
Restrict Uses and Disclosures

You have the right to request that ASC restricts uses and disclosure of your health information for activities related to payment, healthcare operations, and treatment. ASC will consider, but may not agree to, such requests. Note: This issue generally applies to insurance issues, which ASC does not perform at this time.
Alternative Communication

ASC will accommodate reasonable requests to communicate with you at a certain location or in a certain way. For example, if you prefer the office to leave a message on your cell phone and not your home phone, we will do our best to honor that request.

Please keep in mind that email may be used for scheduling confirmations as well as private information

Copy of Health & Privacy Information

You have a right to obtain a copy of health and privacy information that is contained in your records.
Amend Health Information
You have the right to request an amendment to health information contained in your record. ASC may deny your request to amend your health information if ASC did not create the health information, if the information is not part of ASC ’s records, if the information was not available for inspection, or the information is not accurate and complete.
You may complain to the Secretary of Health and Human Services (HHS) if you believe your privacy rights have been violated. You will not be penalized for filing a complaint. You can do so by contacting the Secretary of HHS at 200 Independence Avenue, S.W., Washington, D.C. 20201 or by calling (202) 619-0257.
ASC’s Responsibilities
ASC is required by a federal law to keep your health information private, to give you notice of ASC’s legal duties and privacy practices, and to follow the terms of the notice currently in effect.

This Notice is Subject to Change
The terms of this notice and ASC’s privacy policies may be changed at any time. If changes are made, the new terms and policies will then apply to all health information maintained by ASC. If any material changes are made, ASC will distribute a new notice to participants and beneficiaries as well as update its website.

Your Questions and Comments
If you have questions regarding this notice, please contact ASC at 585-967-6996
( Type Full Name )
Thank you for choosing Authentic Self Counseling. I realize that starting counseling is a major decision and you may have many questions. This document is intended to inform you of my policies, State and Federal Laws, and your rights. If you have other questions or concerns, please ask and I will try my best to give you all the information you need.

Stacey Steinmiller earned a Bachelor of Science Degree in Psychology at Nazareth College of Rochester and a Masters Degree in Mental Health Counseling from Roberts Wesleyan College. She is licensed by the State of New York as a Licensed Clinical Social Worker. Stacey Steinmiller, LCSW practices person-centered, cognitive-behavioral, mindfulness-based, interpersonal and EMDR psychotherapies. Other treatment approaches are used depending on the individual or condition. Treatment practices, therapeutic approaches, and plan limitations and risks will be discussed with you at your first session.

Your verbal communication and clinical records are strictly confidential except for:
1) Information shared with consultants and potential referral sources
2) Information (diagnosis and dates of service) shared with your insurance company to process your claims as well as information needed for billing and collection purposes
3) Information you and/or your child or children report about child/vulnerable adult abuse; then, by New York State Law, a mental health professional is obligated to report this to Child Protective Services and/or legal authorities
4) Where you sign a release of information to have specific information shared
5) If you provide information that informs that you are in danger of harming yourself and/or others
6) Information necessary for case supervision and/or consultation
7) When release of information is required by law

I have added you to my HIPPA compliant client portal system called CounSol. Communication through this means is the safest way to communicate electronically. You can always reach me through my phone number and leaving me a voicemail. If there is some ongoing work that you would like to keep me informed of there is a journal option on the client portal that can be shared with me and you can put down your thoughts and questions there and I can easily access them to discuss at our following appointment. I keep my phone locked for security purposes. I do not save client names in my phone so that your name does not show up, so please indicate who you are. I do respond to text messages but do not provide any clinical services via text, and remember this is not a HIPPA compliant means of communication. I will not communicate via social media outlets; however, you can follow my business on various platforms if desired. The newsletter to my blog/podcast is not HIPPA compliant and under your discretion to subscribe to.

If an emergency situation for which the client or their guardian feels immediate attention is necessary, please feel free to call, however I often screen my calls if it is outside of office hours. If I am not available, please do not leave a message, but rather hang up and contact the emergency services in the community, such as Emergency 911, Lifeline or Mobile Crisis at 211 or 275-5151, or local emergency room for immediate assistance. Stacey Steinmller will follow those emergency services with standard counseling and support to the client or the client's family. Beware that E-mail, text messages and social networking sites are not confidential. If it is not an immediate emergency feel free to leave a message, but beware that I may not respond until business hours or until our next session.

Your costs for therapy will be specified at the beginning of treatment. Occasionally, it may be necessary to increase fees due to inflation. If this occurs during your treatment, you will be given 60 days notice prior to the increase. The fee is set on the basis of a 50 minute session. Payment will be required at the time that service is received. In circumstances of unusual financial hardship, a sliding scale fee may be offered. Clients who start out on a sliding scale will revisit the fee quarterly and make adjustments based on changes in income. Regardless of whether you are at the office to begin your session on time, I will need to end the session at the scheduled end time. You will still be responsible for the full 50 minute session fee. If I am late at the beginning of the session, I will make up that time with you. If you have any questions regarding payments, you are encouraged to talk with your counselor.

Your fee for 55 minutes of individual therapy will be $125.

Twenty-four-hour cancellation is required in order to avoid paying the full fee for a missed appointment.
Voice mail is available 24 hours a day to receive your call. If you fail to cancel a scheduled appointment, this appointment time cannot be provided to another client and you will be billed for the entire cost of your missed appointment. A full appointment fee is charged for missed appointments or no show cancellations with less than 24 hours advance notice. You are welcome to cancel and reschedule your session yourself on your client portal, however changes are not allowed after the 24 hour window and contact will have to go through me.

Payment is due when services are received. Cash, checks, credit cards, and FSA/HSA cards are all accepted. You can also sign into your client portal and pay via paypal before our scheduled appointment is preferred. You will receive a bill via e-mail the morning of our session. Make checks payable to Stacey Steinmiller or Authentic Self Counseling. There will be a $25 charge on all returned checks. I am considered an out of network provider for insurance companies so if you are looking to lower the costs of services and qualify for a diagnosis, then I can provide you with a superbill and you can submit it to your insurance for possible reimbursement. It is then your responsibility to seek reimbursement from your insurance company.

Consent for Treatment

I/We have read, understand, and agree to the above policies. I/We have had the opportunity to ask questions.
I/We consent to treatment by Stacey Steinmiller of Authentic Self Counseling

If you are under 18 years of age, please be aware that the law may provide your parents/guardians the right to examine your treatment records. It is my policy to request an agreement from your parents/guardians that they agree to give up access to your records. If they agree, I will provide them only with general information about our work together unless I feel there is a high risk that you will be harmed, you will seriously harm yourself, or you will harm someone else. In this case, I will notify your parents/guardians of my concern. Before giving your parents/guardians any information, I will discuss this matter with you, if possible, and do my best to handle any objections that you may present regarding my disclosure of this information.

I/We have read, understand, and agree to the above policies. I/We have had the opportunity to ask questions.
( Type Full Name )