INFORMED CONSENT FOR PROFESSIONAL SERVICES AGREEMENT: My signature below indicates that I voluntarily agree to participate in the assessment and counseling as offered by Nu Leaf Therapy.  I acknowledge that no guarantees have been made to me regarding the outcome of my therapy.  I understand my rights and responsibilities as stated in this document.  I acknowledge receipt of this document and all the information contained in this document along with the HIPAA Privacy Practices (located via https://nuleaftherapy.secure-client-area.com/portal).  I agree that my therapist may withdraw and will not be obligated to provide counseling services if I fail to abide by the terms specified in this document.  

By my signature below, I certify that I am not under a legal disability that prevents me from understanding the terms of this agreement, and I accept all the terms and conditions as herein stated.

It is understood and agreed that I as a client will never tape a session without the express written consent of the therapist. Any acts to tape a session without the knowledge of the therapist invalidates the client/therapist relationship contracted herein.

By signing below I/We acknowledge being informed that the counselor with whom we are contracting for professional counseling services is operating as a sole-proprietor not participating in partnership with the other counselors at Nu Leaf Therapy.  Nu Leaf Therapy provides administrative support as a professional service for each counselor's sole proprietorship.

Cost of Sessions

You and I will agree upon the cost of your session over the phone.  It will also be stated on your scheduled appointment on your client portal (https://nuleaftherapy.secure-client-area.com/portal.  The cost of the session depends on the counseling medium used, the date, the time, and any financial hardship that you may have.   

You, the client, are responsible for the cost of any technology at your location, such as a computer, device, phone, phone call charges, software, and headset.

If you are in need of additional support between sessions and choose to use telephone calls, secure messaging or chat, you will be billed $1 per minute for every minute that exceed 10 in duration.

Counseling by means of secure messaging is billed at $40 per message that you send with a maximum of 300 words per message.  You will get one message response per message that you send.

Some insurance providers and policies will not reimburse for telemental health services.  Many insurance carriers will reimburse for telemental health sessions conducted using video conferencing, within their given parameters.

-        3/18/2020- Due to the current Coronavirus Pandemic, many providers are reimbursing for telemental health services. It will be important for you to understand your benefit coverage.  For benefit coverage questions, please call the customer/member service number on the back of your insurance card.  It is your responsibility to check before your initial visit to know your plan's limitations, deductibles and exclusions.  

-         Verification of benefit coverage is not a guarantee of claim payment.  All benefits are subject to the terms and conditions (e.g. authorizations, network requirements) outlined in your member contract with your insurance company.  We have no authority to make representations to you regarding coverage of items or services covered.  Some plans require pre-authorization.  It is your responsibility to engage this process with your insurance company before expecting insurance payment.

-        You are responsible to pay any copayment and/or deductible at the time of your counseling session.  You are also responsible for any payments in which your insurance provider refuses to reimburse.

 -       At this time, I am an in-network provider for Blue Cross and Blue Shield, United Behavioral Health (UBH), Medicaid, and Medicare. If you have insurance with whom I am not paneled, I can provide you with an invoice and receipt to provide to your insurance company.

Checks, Cash (in-person appointments only), and all major credit cards are acceptable for payment.  You may pay via your client portal on https://nuleaftherapy.secure-client-area.com/portal. Receipts for all of your payments will be available via your client portal under your billing tab. Payments are due at the time services are rendered. 

The receipt of payment may also be used as a statement for insurance if applicable to you.  There is a $25 fee for any returned checks. If you pay by credit card you might receive a receipt via email, and it will likely show up on your billing statement.

CANCELLATIONS

I understand that a twenty-four (24) hour notification is an expected courtesy to the therapist who is reserving time for you and to other clients who are waiting to schedule appointments.  

You must give a 24 hour advanced notice to cancel an appointment.  The advance notice is standard in our profession.  If you are more than 15 minutes late for your appointment, it is considered a missed appointment and you will be responsible for the fees for that session.  If you miss or fail to cancel an appointment within 24 hours, you will be charged up to the entire session fee.  Insurance plans do not pay for such charges.  Payment for the missed session must be timely or we cannot continue to schedule appointments.  By not canceling your appointment as stated in the cancellation policy, you are agreeing to the price of your session as stated on (https://nuleaftherapy.secure-client-area.com/portal

COURT PROCEEDINGS

FEES FOR CHART REVIEW, NOTE PRODUCTION, RELEASE OF INFORMATION, PREPARATION OF FORMS, REQUEST FOR INFORMATION/DOCUMENTATION, CLIENT DISCUSSIONS, WRITTEN REPORTS, RESPONSE TO SUBPOENAS, COPIES 

If it becomes necessary for NLT to provide documents in response to a court proceeding, whether by agreement to provide documents, or not, the following fees apply in addition to any other applicable fees:

1.         Client discussions $110.00 hour;

2.         Chart review, note production, release of information, preparation of forms: $110.00 per hour;

3.         Request for information/documentation $110.00;

4.         Written reports: $195.00 hour;

5.         Response to Subpoena*: $400.00 non-refundable fee per subpoena and $.50 per page for copies;

6.         Copies are billed at $.50 per page.

*Subpoena: No records will be released until the requesting party deposits the non-refundable fee of $400.00 with NLT.  Upon receipt of the non-refundable fee of $400.00, records will be reviewed, compiled and provided under seal to the presiding Judge.  Records will not be released directly to a party by subpoena.  We feel that confidentiality is of the utmost importance and will rely upon the presiding Judge to determine whether and in what fashion records should be released or disclosed to litigants.  If your attorney tries to circumvent this policy by making threats and/or attempting to subpoena therapists or office personnel to court, you will receive a bill for all time spent, including our legal fees.  Copies are charged at $.50 per page in addition to the $400.00 non-refundable fee.

COURT RELATED FEES AND TESTIMONY -NLT does not conduct therapy and counseling for the purpose of providing expert witness testimony.  NLT will not be compelled to provide testimony through subpoena and is under no obligation to provide testimony as a result of the counseling relationship.  NLT will not participate in litigation.  NLT has the right to refuse service if you are involved in litigation.  However, NLT recognizes that there may be situations where it is in the best interests of the client to provide such testimony and in the sole discretion of the therapist, expert testimony may be provided.  No testimony will be provided in any manner related to counseling/therapy unless an agreement is reached between NLT and the requesting party.  If NLT agrees to provide expert witness testimony, the requesting party shall deposit a non-refundable retainer with NLT.  The amount of the non-refundable retainer is subject to the discretion of NLT based upon the expected amount of time required as well as the expected time out of the office.  These fees are in addition to normal charges for counseling and therapy.  Deposition and court testimony is handled in the same manner as expert witness testimony.  No therapist may be compelled to provide expert testimony through a deposition subpoena, court testimony or otherwise.  If it becomes necessary for your therapist to provide documents or testimony in response to a court proceeding, whether by agreement to provide expert testimony, or not, the following fees apply in addition to any other applicable fees:

Court/legal records review $110.00/hour; Written reports for courts $195.00/hour; Deposition Testimony: Non-refundable retainer of $1,500.00, payable in advance, which will include preparation time and deposition testimony of not more than seven hours; time spent beyond seven hours of testimony is charged are $150.00 per hour and billed in increments of 15 minutes; Court Testimony: Non-refundable retainer of $1,500.00, payable in advance, which will include preparation time and court testimony of not more than seven hours; time spent beyond seven hours of testimony is charged at $150.00 per hour and billed in increments of 15 minutes; Expert Witness Testimony: Non-refundable retainer of $2,500.00, payable in advance, which will include preparation time and court testimony of not more than seven hours; time spent beyond seven hours of testimony is charged at $250.00 per hour and billed in increments of 15 minutes; Copies are billed at $.50 per page.        

All fees must be paid in full before any work is performed in relation to deposition, court and expert witness testimony and must be paid in full no later than ten days prior to any testimony.  Although our policy is not to participate in litigation unless we agree to do so, the fees set forth herein are in recognition that a client or litigation may attempt to force testimony through the court process in order to circumvent our fee structure.  In the event that this occurs, we will resist all efforts to procure our testimony without adequate compensation and our agreement and will ask the court to impose the fee structure herein as a condition of our testimony.  By signing below, you are accepting this as a condition of our firm providing therapy and counseling.

If a person responsible for payment defaults on any payment obligation as called for in this agreement, NLT   will have the right to take any legal action to collect the debt.  By signing this agreement, you are acknowledging and agreeing that should NLT turn this matter over to an attorney for collection or if it initiates litigation against you for any delinquent debt, that you agree to be responsible for paying all of NLT's attorney's fees and expenses incurred as a result of the collection efforts. 

Confidentiality and Records

All of your PHI (Protected Health Information) is kept for a minimum of five years.

It is your clinician's personal, professional, and legal obligation to keep all of your protected health information (PHI) confidential, with some exceptions.  The Notice of Privacy Practices form on   https://nuleaftherapy.secure-client-area.com/portal provides detailed information on how private information about your health care is protected, and under what circumstances it may be shared.

Other than the exceptions listed on the Notice of Privacy Practices form, your therapist will be the only person viewing your information. 

In the event of your clinician's death, retirement, or incapacity, a records custodian will contact you to manage your records.  This records custodian will be responsible for responding to any request for records you may have, and for safely destroying your records after the legal time frames for storing them have been satisfied.  They will also contact you at the time of transfer of records.  If you are a current client, the same records custodian will assist in providing appropriate referrals for further treatment. 

If you make payments via credit card there is the possibility that you may receive an email receipt, and the payment will show on your billing statement.  If you are using medical insurance, we may be required to disclose your records to the insurance provider for reimbursement.

The following information explains how we handle and store your PHI while you are receiving counseling.  Although it is not guaranteed that these methods will prevent 100% of confidentiality breaches, they are designed with the intention of supporting the confidentiality of all clinical communications:

On-site:

Your information is stored via https://nuleaftherapy.secure-client-area.com/portal/ which is designed for healthcare and provides a Business Associate Agreement for HIPAA compliance.  https://nuleaftherapy.secure-client-area.com/portal uses point-to-point, federal approved, encryption.  https://nuleaftherapy.secure-client-area.com/portal retains your records indefinitely. Any devices of mine that contain your records or identifying information are full disk encrypted and kept secure. Any paper with your personal information is kept in a locked cabinet behind a locked door.

Email:

Email is not always secure.  However, you have the option to request appointment reminder to be sent via email.

I do not use email with clients.  However, you can use secure messaging with your clinician through https://nuleaftherapy.secure-client-area.com/portal, unless you request otherwise. 

https://nuleaftherapy.secure-client-area.com/portal stores our email correspondence.

Chat:

All chat correspondences will be done through https://nuleaftherapy.secure-client-area.com/portal, unless you request otherwise.  https://nuleaftherapy.secure-client-area.com/portal stores our chat correspondence.

Video Conferencing:

All video conferencing correspondence will be done through https://nuleaftherapy.secure-client-area.com/portal , which is encrypted to the federal standard.

Texting:

For the sake of your privacy, I do not use SMS or MMS texting with clients.  However, you can use secure texting with me by using https://nuleaftherapy.secure-client-area.com/portal. You can view the instructions on the client portal. Counsol.com stores the secure texts that you send me.

Risks / Client's Responsibilities / Client's Protection

When using technology for communication, there is a risk that it may be forwarded, intercepted,

circulated, stored, or even changed, and the security of the devices used may be compromised.   Although I make reasonable efforts to protect the privacy and security of all electronic communication with you, it is not possible to completely secure the information.

If you use any other methods of electronic communication with me, other than the means recommended by me, there is a reasonable chance that a third party may be able to intercept that communication. 

With the use of technology, it is important to be aware that family, friends, co-workers, employers, and hackers may have access to any technology, devices, or applications that you use. 

I encourage you to only communicate through a computer, or any other device that you know is safe, and to follow the safety measures that are detailed on the "Privacy Measures" document provided on https://nuleaftherapy.secure-client-area.com/portal.

You are responsible for reviewing the privacy settings and agreement forms of any applications or technology you use.

Please contact your clinician with any questions that you may have on privacy measures.

Contact information

When you need to contact your clinician for any reason, these are the most effective ways to get in touch in a reasonable amount of time:

-    By phone (+1-601-265-4014). You may leave messages on the voicemail, which is confidential.

-    By secure messaging using your client portal on (https://nuleaftherapy.secure-client-area.com/portal.)

Please refrain from making contact with your clinician using any social media messaging systems such as Facebook Messenger or Twitter. These methods have very poor security and I am not prepared to watch them closely for important messages from clients.

Please refrain from creating reviews of your clinician's services online.  Online reviews are for the public to see and therefore they would put your confidentiality at risk.

Any text-based communication may become part of your record.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW CAREFULLY.

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information.  "Protected Health Information" is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your therapist, our office staff, and others outside of our office that are involved in your care and treatment for the purpose of providing mental health care services to you, to pay your health care bills, to support the operation of the therapist's practice, and any other use required by law.

TREATMENT:  We will use and disclose your protected health information to provide, coordinate, or manage your mental health care and any related service.  This includes the coordination or management of your mental health care with a third party.  For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

PAYMENT:  Your protected health information will be used, as needed, to obtain payment for your health care services.  For example, obtaining approval for psychological testing or a hospital stay may require that your relevant protected health information be disclosed to your health plan to obtain approval for the psychological testing or hospital admission.

HEALTHCARE OPERATIONS:  We may use or disclose, as needed, your protected health information in order to support the business activities of your therapist's practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, marketing and fundraising activities, and conducting or arranging for other business activities.  For example, we may disclose your protected health information to medical students that see patients at our office.  In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your therapist.  We may also call you by name in the waiting room when your therapist is ready to see you.

We may use or disclose your protected health information in the following situations without your authorization.  These situations include:  as required by law; public health issues as required by law; communicable diseases; health oversight; abuse or neglect; food and drug administration requirements; legal proceedings; law enforcement; coroners, funeral directors, and organ donation; research; criminal activity; military activity and national security; workers' compensation; inmates; required uses and disclosures.  Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and required used and disclosures will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization at any time in writing, except to the extent that your therapist or the therapist's practice has taken action in reliance on the use or disclosure indicated in the authorization.

YOUR RIGHTS

The following is a statement of rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.  Under Federal Law, however, you may not inspect or copy the following records:  psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.  This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment, or healthcare operations.  You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restrictions to apply.

Your provider is not required to agree to a restriction that you may request.  If your provider believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.  You then have the right to use another healthcare professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location.  You have the right to obtain a copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your provider amend your protected health information.  If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.  We reserve the right to change the terms of this notice and will inform you by mail of any changes.  You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact of your complaint.  We will not retaliate against you for filing a complaint.

This notice becomes effective on or before March 18, 2020.

 I have received a copy of my privacy rights under the Health Insurance Portability Act.  I agree to all of these policies and I understand that I may contact this office to make any changes I require.

NONDISCRIMINATION POLICY 

As a recipient of federal financial assistance, Nu Leaf Therapy does not exclude, deny benefits to, or otherwise discriminate against any person on the grounds of race, color, sex, or national origin, or on the basis of disability or age in admission to, participation in, or receipt of the services and benefits of any of its programs and activities or in employment therein, whether carried out by Nu Leaf Therapy directly or through a contractor or any other entity with whom the Nu Leaf Therapy arranges to carry out its programs and activities. 

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, Section 1557 of the Affordable Care Act of 2010, and Regulations of the U.S. Department of Health and Human Services issued pursuant to the Acts, Title 45 Code of Federal Regulations Part 80, 84, 91, and 92. (Other Federal Laws and Regulations provide similar protection against discrimination on grounds of sex and creed.) 

In case of questions concerning this policy, or in the event of a desire to file a complaint alleging violations of the above, please contact:

Nu Leaf Therapy

Coordinator: Dr. Roslyn L. Ashford, LPC

Telephone number: 601-265-4014

This practice does not utilize a Telecommunication Device for the Deaf (TDD) 

It is the policy of Nu Leaf Therapy to provide communication aids (at no cost to the person being served) to Limited English Proficient (LEP) persons, including current and prospective patients, clients, family members, interested persons, et al., to ensure them a meaningful opportunity to apply for, receive or participate in, or benefit from the services offered. The procedures outlined below will reasonably ensure that information about services, benefits, consent forms, waivers of rights, financial obligations, etc., is communicated to LEP persons in a language which they understand. Also, they will provide for an effective exchange of information between staff/employees and patients/clients and/or families while services are being provided.

PROCEDURE: 

1. Nu Leaf Therapy will designate practice administrator to be responsible for implementing methods of effective communication with LEP persons. 

2. The practice administrator will: 

- Maintain and routinely update a list of all bilingual persons, organizations, and staff members who are available to provide bilingual services, and 

- Develop written instructions on how to gain access to these services, i.e., contact persons, telephone numbers, addresses, languages available, hours available, fees and conditions under which the person(s) are available. 

- Post a short "tagline" written in at least the top 15 languages spoken by individuals with limited English Proficiency in relative state informing that language assistance service is free of charge. 

3. In order to ensure effective communication and to protect the confidentiality of the client, information and privacy, the client will be informed that the services of a qualified interpreter are available to him/her at no additional charge. Only after having been so informed, the client may choose to rely on a family member or friend in an emergency situation. The choice of the client and presence of an interpreter will be documented after every visit.

Nu Leaf Therapy will take such steps as are necessary to ensure that qualified persons with disabilities, including those with impaired sensory or speaking skills, receive effective notice concerning benefits or services or written material concerning waivers of rights or consent to treatment. All aids needed to provide this notice are provided without cost to the person being served. 

For Persons With Hearing Impairments: Qualified sign-language interpreter for persons who are deaf/hearing impaired and who use sign-language as their primary means of communication, the following procedure has been developed and resources identified for obtaining the services of a qualified sign-language interpreter to communicate both verbal and written information: 

Agency to provide service: 

Office on Deaf and Hard of Hearing

Amy Ainsworth, Interpreter
aainsworth@mdrs.ms.gov
(601) 898-7052 Voice/TTY

or 

Video Remote Interpreting
8555 16th Street
Suite 400
Silver Spring, MD  20910
https://bisworld.com/video-remote-interpreting-vri/
shawn.huff@bisworld.com
1-800-471-6441 ext. 141
(301) 587-8885 ext 141
(301) 565-0366 Fax

For Persons with Visual Impairments: The reader/staff will communicate the content of written materials concerning benefits, services, waivers of rights, and consent to treatment forms by reading them out loud to visually impaired persons. 

For persons With Speech Impairments: Writing materials are available to facilitate communication concerning program services and benefits, waivers of rights, and consent to treatment forms.

This provider/vendor and all of its programs and activities are accessible to and usable by disabled persons, including persons with impaired hearing and vision. Access features include: 

ï,§ Convenient off-street parking designated specifically for disabled persons. 

ï,§ Curb cuts and ramps between parking areas and buildings. 

ï,§ Level access into first floor level. This location is first floor level only.

ï,§ Fully accessible offices, meeting rooms, and bathrooms.

 ï,§ A full range of assistive and communication aids provided to persons with impaired hearing, vision, speech, or manual skills, without additional charge for such aids: 

If you require any of the aids listed above, please let the receptionist know.