OFFICE POLICIES, PRIVACY & CONFIDENTIALITY
Services are by appointment only. The length of the appointment time varies on the basis of services provided. Individual therapy is generally scheduled for 45 to 50 minutes and this is known as the "clinical hour." Because the appointment is reserved for you, it is necessary to charge $85.00 for appointments which are not canceled 24 hours in advance, unless in fact they are occasioned by circumstances which we would both define as an emergency. Failure to provide a 24-hour notice of cancellation generally means that some other person is not able to use that appointment time.
The law protects the privacy of all communications between a patient and a provider, psychiatrist and psychologist. In most situations, information can only be released about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent.
Occasionally it may be helpful to consult other health and mental health professionals about a case. During a consultation, every effort will be made to avoid revealing the identity of a patient. The other professionals are also legally bound to keep the information confidential. If you don't object, you will not be told about these consultations unless it is felt that it is important to our work together. Also, you should be aware that privilege and confidentiality apply only to the identified patient. If you are seen in an adjunct or collateral fashion, then you do not have these rights as outlined. An example would be a patient's spouse who is not an identified patient but who is seen in session for the benefit and progress of the patient.
You should be aware that we practice with other mental health professionals and that we employ an administrative staff. In most cases, protected information is shared with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All 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.
Disclosures required by health insurers or to collect overdue fees as discussed elsewhere in this booklet. If a patient threatens to harm himself/herself, our office may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection.
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 the professional services provided, such information may be protected by patient privilege law. We cannot provide any information without your (or your 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 our office to disclose information.
If a government agency is requesting the information for health oversight activities, our office may be required to provide it for them.
If a patient files a complaint or lawsuit against our office, we may disclose relevant information regarding that patient in order to defend the practice.
If you file a worker's compensation claim, and we have examined or treated you in regard to such claim, we must, upon appropriate request, provide a report to the patient's employer or the employer's insurance company.
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.
If we have reason to suspect that a child under 18 has been injured as a result of physical, mental or emotional abuse or neglect or sexual abuse, or that an adult has been or is being abused, neglected or exploited or is in need of protective services, the law requires that we file a report with the appropriate government agency, usually the Department of Social and Rehabilitation Services. Once such a report is filed, we may be required to provide additional information.
If a patient communicates an imminent, specific threat of harm against a specific individual and we believe that there is a substantial risk that the patient will act on that threat in the foreseeable future, 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 such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.
A law in Kansas may allow, under certain circumstances, disclosure of records to the Behavioral Sciences Regulatory Board under subpoena if there were to be serious misbehavior or illegal activity by anyone in our group. You should be aware that we will always try to preserve your confidentiality rights and specific questions can be addressed with your provider or Dr. Cappo in this regard. This information is provided to keep you as fully informed as possible of any potential limitations of confidentiality. 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. In situations where specific advice is required, formal legal advice may be needed.
I understand that my treatment provider generally may not condition mental health services upon my signing an authorization unless the mental health services are provided to me for the purpose of creating health information for a third party.
I understand that information used or disclosed pursuant to a release authorization may be subject to redisclosure by the recipient of your information and no longer protected by the HIPAA Privacy Rule.
Our building uses video surveillance for security. Some images are viewable by our staff and employees and are not recorded in any form. Some images are stored electronically on a hard disk that is then overwritten when full. Only in the case of an incident of some type are the stored images reviewed. If you have any questions or concerns in this area please talk to Dr. Cappo.
During regular office hours, calls are answered by the receptionists in the office. In the evening, calls are answered by an answering service and if there is an emergency they will contact your practitioner. If it is a life-threatening emergency, go to the nearest hospital emergency room. Please be aware that if you subscribe to certain telephone features, this may affect confidentiality or our ability to contact you. If you have Caller-ID services and we phone from the office, then our practice name may show up on your Caller-ID and be available to others in the household. We do not block the CallerID signal in outgoing calls from our office. Also, please be aware that should your telephone not accept any blocked calls, then it may limit our ability to contact you at times. There are times when only blocked calls may be available from specific locations. If we are calling from one of those locations and your telephone does not accept blocked calls, there will be a delay in eventually contacting you. If you have concerns along these lines, please discuss this with your practitioner. Unless you tell us otherwise, we may attempt to contact you at any of the numbers you have provided us.
Your initial appointment is often called an "initial evaluation." This appointment is scheduled for you to discuss your concerns and problems from your point of view. There may be time during this appointment to obtain historical and other background data or this information may be gathered at subsequent sessions. In situations of crisis, the usual format of an "initial evaluation" is not followed in the hope that the time might be used to resolve or relieve the immediate crisis. As part of the "initial evaluation" new clients are sometimes requested to complete at least one questionnaire concerning their beliefs, experiences, thoughts and feelings which will then be scored using statistical norms. The results of this "psychological test" will allow us to "measure" your concerns and problems. This booklet contains a copy of our Policies and Practices to Protect the Privacy of Your Health Information. You should review this information and ask any questions of your provider or Dr. Cappo.
Your initial appointment is often called an "initial evaluation." This appointment is scheduled for you to discuss your concerns and problems from your point of view. There may be time during this appointment to obtain historical and other background data or this information may be gathered at subsequent sessions. In situations of crisis, the usual format of an "initial evaluation" is not followed in the hope that the time might be used to resolve or relieve the immediate crisis. As part of the "initial evaluation" new clients are sometimes requested to complete at least one questionnaire concerning their beliefs, experiences, thoughts and feelings which will then be scored using statistical norms. The results of this "psychological test" will allow us to "measure" your concerns and problems. This booklet contains a copy of our Policies and Practices to Protect the Privacy of Your Health Information. You should review this information and ask any questions of your provider or Dr. Cappo. Under certain conditions a provider-patient relationship may not exist. This may include some forensic evaluations or evaluations/treatment at the request of a third party such as an employer, state or federal agency, court or insurer. The agency will pay for the service and may control access to reports or records. In such cases, the relationship actually exists between our practice and the referring agency rather than between you and your provider.
OTHER AREAS OF EMPHASIS
Clinical Associates, P.A. offers Attention-Deficit Disorder evaluations and treatment, intellectual functioning and achievement evaluations, court-involved domestic violence evaluation and treatment, and forensic and court-ordered evaluations.
Clinical Associates, P.A. is a Substance Abuse Treatment and Recovery (SATR) licensed outpatient treatment, diagnostic and referral service as well as Juvenile Court Services and Johnson County Drug/Alcohol Board service provider.
OTHER PSYCHOLOGICAL SERVICES
Infrequently, a patient's distress remains or becomes so high that hospitalization or the use of medication must be considered. Psychologists and Social Workers are not physicians, and consequently do not prescribe medication; however, at times psychologists and social workers may treat patients in hospitals. In cases where medications or hospitalization may be required, this will be discussed in advance with the patient and, if necessary, with other responsible individuals. We work with several psychiatrists, and we often collaborate on issues of medication, hospitalization and second opinion; in this way the patient who has these needs is better served.
Termination of treatment may occur at any time and may be initiated by either the patient or clinican. We request that if a decision is being made to terminate, that a final termination session be scheduled to explore the reasons for termination. Termination itself can be a constructive, useful process. If any referral is warranted, it will be made at that time.
At any time, our patients may question and/or refuse therapeutic or diagnostic procedures or methods, or gain whatever information they wish to know about the process and course of therapy. Patients are also assured of confidentiality which is protected by both ethical practice and by Kansas law. There are, however, important exceptions to confidentiality that are legally mandated. In general terms, these exceptions include: (1) Possible notification of relevant others if we judge that a patient has an intention to harm another individual or themselves; (2) we are also obliged by the law to report any incidence of suspected child abuse, neglect, or molestation in order to protect the children involved; (3) in legal cases, we or our records may be subpoenaed by the court. Confidentiality will be respected in all cases, except as noted above, and in those additional cases where in our clinical judgment the maintenance of confidentiality is, in fact, destructive to the individual. In those situations, we will inform our patients of our judgment and they will have the final decision as to whether we maintain confidentiality. Please understand that all files are kept confidential in their use by the staff of Clinical Associates, P.A. Your written consent is required for any release of information by Clinical Associates, P.A. staff to other persons, organizations or agencies except in the rare cases of court orders, child abuse, life threatening situations and national security issues. If you provide us a fax number with instructions to fax information to you, we cannot assure confidentiality or security at the receiving end. Also be aware that while your provider may be available to you by e-mail, this also is not a secure or confidential form of communication. If you receive a response by e-mail, then such information should not be forwarded to others and should be considered specific to your private use. There may be other relevant exceptions to confidentiality which are not included here or that arise following printing of this document. Please ask your therapist or Dr. Cappo any questions you may have in this area. You have the right to discontinue at any time, except in cases where the treatment or assessment has been ordered by the court. Clinical Associates, P.A. may discontinue treatment if it becomes reasonably clear that you are not benefiting from treatment.
Disclosing information received from other agencies or doctors is subject to the Drug Abuse Office and Treatment Act of 1972 (21 USC 1175) Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (42 USC 4582) as follows:
Prohibition on Redisclosure: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 CFR Part 2) prohibit you from making any further disclosure of this information except with the specific written consent of the person to whom it pertains. A general authorization for the release of medical or other information if held by another party is not sufficient for this purpose. Federal regulations state that any person who violates such provision of this law shall be fined not more than $500 in the case of a first offense, and not more than $5,000 in the case of each subsequent offense.
PATIENTS WHO ARE DEPENDENTS
If you are requesting our services as the guardian or parent of a child, or the guardian of a dependent adult, the same general practice as outlined above will apply. However, as your child's therapist, it is important that your child is able to completely trust us. As such, we keep confidential what your child says in the same way that we keep confidential what an adult says. As the parent or guardian, you have the right and responsibility to question and understand the nature of our activities and progress with your child, and we must use our clinical discretion as to what is an appropriate disclosure. In general, we will not release specific information that the child provides; however, we feel it appropriate to discuss with you, the parent or guardian, your child's progress and your participation in their treatment. Children over the age of 13 have specific rights and should sign pertinent forms in addition to their parent or guardian.
The fees for our services are based on the usual, customary, and reasonable fee profiles for this area. Our charges are available in the Welcome book, which can be downloaded, or you can contact the office for more specific informaiton. We encourage you to discuss fees at any time, and our patients are expected to pay for services when provided unless arrangements have been made in advance. With limited exceptions, when our psychological reports are sent to a third party, payment in full is necessary prior to release of our findings. For your convenience, we accept Mastercard, Visa, Discover and American Express. Please feel free to discuss any concerns about fees with your practitioner directly.
Payment is expected at the time services are rendered unless other specific arrangements have been made. Payment of fees is an important part of our work together. Please discuss fee issues with your provider directly should you have difficulties or concerns. Dr. Cappo is always available to discuss fees with you personally.
Please understand that failure to pay your bill may result in specific information being disclosed to a collection agency to facilitate payment. This information would include demographic information including your name, how you might be contacted, the amount you owe and for what specific services. Specific clinical information about your problems will remain confidential. You will receive written notification that this will happen at the address supplied to CA. You will be notified of a date by which you must contact the office to make arrangements for payment or have your account turned over to collection. It is your responsibility to maintain accurate phone and mailing contact information with our office.
BILLING AND TRANSCRIPTION
Our office contracts with reputable third parties at times to provide various support services. Such services could include, but are not limited to transcription or billing. Any vendor who provides such services to us is committed to the same levels of confidentiality that we apply here in our practice.
If you have a health insurance plan, your visits may be reimbursed by your insurance company. Our office will file most insurance claims for you. Your signature on the appropriate form allows our office to release relevant information to facilitate reimbursement. At your request, we will be happy to discuss with you the "diagnosis" that we are releasing to your insurance carrier. While a patient's diagnosis is very sensitive information and is generally treated as such by insurance carriers, we cannot guarantee how any particular insurance carrier or employer respects this information. If you prefer that we do not release information to your insurance carrier for reimbursement purposes, or if your insurance carrier fails to reimburse you in a manner which you expected, you will remain responsible for the fee for services.
Many individuals are members of preferred provider plans or health maintenance organizations with whom we have contractual obligations. Please inform us in advance should you be eligible for these contracted services. It is the patient's responsibility to obtain insurance pre-authorization for all office visits. Failure to do so may result in out-of-pocket expense.
In situations where there is a court order, mandate or recommendation, it is often the case that an insurance company or managed health organization will not find medical necessity. This is explained up front in such cases and we ask that a form be signed, stating that the individual knows that they are responsible for all charges incurred whether or not they are covered by insurance.
We again welcome you and anticipate our work together will be beneficial to you.
For more information you may contact us at 913-677-3553 or by fax at 913-677-3282
Our website address is www.clinical-assoc.com
For more information email firstname.lastname@example.org or any of our professional staff may be reached by email at mailto:email@example.com For example, Dr. Cappo can be reached at firstname.lastname@example.org. Please include the hyphen for Dr. McNeley-Phelps and Rennie Shuler-McKinney. Our support staff can be reached at email@example.com.
Dr. Cappo has a financial interest in STAT Corporation which provides support services, including transcription, to our practice. Additionally, he is a consulting psychologist for the Overland Park Police Department, Prairie Village Police Department, KU Medical Center Police Department and Johnson County Community College Security Department. He performs work on a regular basis for Elizabeth Layton Center in Paola. He also has contracts with the Federal Bureau of Prisons and the Federal Drug & Alcohol Prevention Services Program to provide both mental health and substance abuse evaluations and treatment. He provides services to the Drug Enforcement Agency (DEA), Immigration & Customs Enforcement (ICE) and Transportation Security Agency (TSA) and may provide services to other governmental entities or agencies which may not allow affiliation disclosure by name.
Dr. Lieberman is associated with Jewish Family Services. She provides services to Immigration & Customs Enforcement (ICE) and may provide services to other governmental entities or agencies which may not allow affiliation disclosure by name.
Dr. Davenport is affiliated with Truman Medical Center.
Dr. Fernandez consults with the Overland Park Police Department and several other area police departments.
Lila Peckham-Wickman is affiliated with Sharon Lane Nursing Home facility.
Rennie Shuler-McKinney is affiliated with Shawnee Mission Medical Center.
Mike Crowley & Dr. Abell are affiliated with Elizabeth Layton Center in Paola.
Jeff Cowan is affiliated with Shawnee Mission Medical Center.
It may be that you would qualify for services under these programs at a different rate than you would be charged through our practice. It may be that you would be eligible for different rates from our providers at the various other organizations with which they are involved. If you believe this may be the case, you should discuss this with your provider, the front office staff or Dr. Cappo.