THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Each time we meet a record of your visit is made. This may include, but is not limited to, your symptoms, treatment interventions, diagnosis, test results, progress, your treatment plan, and billing-related information.

MY RESPONSIBILITY

I am required by law to maintain the privacy of your protected health information (PHI) and provide you with a description of my privacy practices. I am committed to the terms of this notice.

HOW I MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION:

The following categories describe examples of the way I may use and disclose protected health information:

For Treatment:

I may use your health information to coordinate treatment or services and/or continuity of care with other healthcare providers.

For Payment:

I may use and disclose your health information to bill and collect payment from you.

For Health Care Operations:

• To remind you that you have an appointment for medical care
• To tell you about health-related benefits or services

When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail.

Future Communications:

We may communicate to you via forms, mail outs or other means regarding treatment options, billing issues, and health related information.

Law Enforcement/Legal Proceedings:

We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.

YOUR HEALTH INFORMATION RIGHTS

Although your health record is the physical property of Tracy L. Helmer, Psy.D., you have the right to:

Inspect and Copy:

You have the right to inspect and obtain a copy of the health information used to make decisions about your care. I may deny your request to inspect and/or receive a copy in certain circumstances. If you are denied access you may request that the denial be reviewed. Another independent, licensed health care professional hosen by Tracy L. Helmer, Psy.D. will review your request and the denial. I will comply with the outcome of the review.

Amend:

If you feel that your health information is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for Tracy L. Helmer, Psy.D. I may deny your request for an amendment and if this occurs you will be notified of the reason for the denial.

An Accounting of Disclosures:

You have the right to request an accounting of disclosures. This pertains to disclosures I make of your health information for purposes other than treatment where an authorization was not required.

Request Restrictions:

You have the right to request a restriction or limitation on the health information I use or disclose about you. You also have the right to request a limit on the health information I disclose about you to someone who is involved in your care or the payment for your care. I am not required to agree to your request. If I do agree, I will comply with your request unless the information is needed to provide emergency treatment.

Request Confidential Communications:

You have the right to request that I communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that I contact you at work instead of your home. I reserve the right to contact you by other means and at other locations if you fail to respond to any communication from me that requires a response. I will notify you in accordance with your original request prior to attempting to contact you by other means or at another location.

A Paper Copy of This Notice:

You have the right to a paper copy of this notice. You may ask me to mail you a copy of this notice at any time.

CHANGES TO THIS NOTICE

I reserve the right to change this notice at any time.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with me. You may also file a complaint with the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

OTHER USES OF HEALTH INFORMATION

Other uses and disclosures of health information not covered by this notice or the laws that apply to me will be made only with your written permission. If you provide me permission to disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, I will no longer disclose health information about you for the reasons covered by your written authorization. You understand that I am unable to take back any disclosures I have already made with your permission, and that I am required to retain my records of the care that I provided to you.

Your signature acknowledges that you have received this notice.

PATIENT REGISTRATION

REQUIRED INFORMATION:

In case of emergency, who should be notified?

INFORMED CONSENT FOR TREATMENT

Who referred you to my practice?: Briefly state what brings you to my practice: How long have you been experiencing these issues?: HOW WOULD YOU RATE THEIR SEVERITY:

MEDICAL/PSYCHIATRIC HISTORY

Do you have any medical conditions? If so, please explain: Please list any other mental health providers, including a psychiatrist that you have seen in the past or are currently seeing: Please list all medications you are taking: Have you ever been hospitalized for psychiatric reasons? If so, when and where?: Have you ever thought about suicide or attempted suicide? If so, please provide detailed information, including thee last time you thought about suicide: Have you ever thought about hurting someone else, or attempted to hurt someone else? If yes, please provide detailed information, including the last time you thought about hurting someone else:

EDUCATION

OCCUPATION

FAMILY INFORMATION

DEVELOPMENTAL HISTORY

Please list any developmental issues you have experienced, such as delays in walking or talking, irrational fears, nightmares, physical or sexual abuse, etc. Please include any life crisis you have experienced such as loss, a victim of violence, divorce, etc.:

CIGARETTE, ALCOHOL, AND DRUG USE

Please list all cigarette, alcohol, and drug use including amounts and frequency: IS THERE A HISTORY OF DRUG OR ALCOHOL ABUSE IN YOUR FAMILY? If so, please explain:

RECREATION

What Do You like to do for fun? What are your interests? Who do you enjoy spending time with?

TREATMENT GOALS

PLEASE LIST THREE (3) GOALS THAT YOU HAVE FOR TREATMENT:

Informed Consent for Telehealth Services

This informed consent for Telehealth contains important information focusing on therapy by using the telephone or the Internet. Please read this carefully and let me know if you have any questions.This signed document represents an agreement between us.

There are benefits and risks of Telehealth. Telehealth provides psychotherapy services remotely using telecommunication technologies, such as videoconferencing or telephone. Telehealth benefits include easier access to care, no transportation or time costs, no need to take time off of work, no childcare expense, increased access, and a more efficient service delivery. Studies demonstrate the Telehealth is as effective, and sometimes more effective, that traditional therapeutic sessions in an office. Telehealth requires technical competence to be helpful.

Although there are benefits to Telehealth, there are some differences between in-person psychotherapy and Telehealth, as well as some risks. There is some risk to confidentiality because Telehealth sessions take place outside of the therapist’s private office. As your psychologist, I am committed to ensuring that your sessions are private and confidential from the provider perspective; however, there is the potential for other people to overhear sessions if you are not in a private place during the session. It is important for you to make sure you find a private place for your session where you will not be interrupted. It is also important for you to protect the privacy of our session on your cell phone or other device. You should participate in therapy only while in a room or area where other people are not present and cannot overhear the conversation.

Should a crisis occur in our session, we agree that if I believe that there is a significant risk to your safety and well-being or that you pose a grave risk to someone else, I will utilize the emergency response team through 911 to maximize everyone’s safety.

For communication between sessions, I typically use text messaging, and sometimes email, with your permission. This tends to be for administrative purposes but, there are times that we may be texting to resolve a concern or question that you have. You should be aware that I cannot guarantee the confidentiality of any information communicated by email or text. Therefore, I will only discuss clinical information by email or text if you are requesting it. Also, I do not regularly check my email or texts, nor do I respond immediately, so these methods should not be used if there is an emergency. Treatment is most effective when clinical discussions occur at your regularly scheduled sessions. But if an urgent issue arises, you should feel free to attempt to reach me by phone. I will try to return your call or text within 24 hours except on weekends and holidays. If you are unable to reach me and feel you cannot wait for me to return your call, contact your family physician, psychiatrist, or the nearest emergency room.

Confidentiality: Because our relationship is confidential, I have a legal and ethical responsibility to exert every effort to protect all communications that are a part of our Telehealth. However, the nature of electronic communication technologies is such that I cannot guarantee that our communications will be kept confidential or that other people may not gain access to our communications. I will try to use updated encryption methods, firewalls, and backup systems when possible to help keep your information private, but there is a risk that communications may be compromised, unsecured, or accessed by others. You should also take reasonable steps to ensure the security of our communications. For example, only use secure networks for Telehealth sessions and have passwords to protect the device you use for Telehealth. The extent of confidentiality and the exceptions to confidentiality that were described in the Informed Consent document still applies in Telehealth.

Please let me know if you have any questions about exceptions to confidentiality or the appropriateness of Telehealth.

If I decide that Telehealth is no longer the most appropriate form of treatment for you, we will discuss options of engaging in in-person therapy and I will provide you with a referral to other treatment providers in your location who can provide appropriate services. I will assist you in transitioning to another professional should that transition be indicated.

Emergencies and Technology

If the session is interrupted because of technology, and you are not having an emergency, please disconnect the session and I will wait 1-2 minutes and then re-contact you via the Telehealth platform on which we agreed to conduct therapy. If you do not receive a call back within 2 minutes, then call me on the phone number I have provided you. If there is a technological failure and we are unable to resume the connection, you will only be charged a prorated amount of actual session time.

Assessing and evaluating threats and other emergencies can be more difficult when conducting Telehealth than in traditional psychotherapy. To address some of these difficulties, we will create an emergency plan before engaging Telehealth services. I have asked you to identify an emergency contact person who is near your location on the intake forms and I will contact that person in the event of a crisis or emergency to assist in addressing the situation. I ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such crisis or emergency. This authorization form is located at the end of this paperwork and MUST be completed as part of the intake packet. On the release you should put your emergency contact person’s name and telephone number and please check the box “emergency information”.

If the session is interrupted for any reason during an emergency, do not call me back; instead, call 911 or go to your nearest emergency room. Carilion Clinic has the Connect program (540.981.8181) for psychiatric emergencies. I ask that you sign a separate authorization form allowing me to contact your emergency contact person as needed during such a crisis or emergency.

Records

The Telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. I will maintain a record of our session in the same way I maintain records of in-person sessions.

Informed Consent

This agreement is intended as a supplement to the general Informed Consent that we will agree to at the outset of our clinical work together and does not amend any of the terms of that agreement. Your signature below indicates agreement with its terms and conditions.

Appointment Notifications

As part of my practice, I provide courtesy reminders of your appointment date and time. This form allows you to indicate how you would like to receive those notifications. Please indicate if you are willing to accept reminders via email or text by indicating your email address or cell phone number and signing this form. If you would not like any email reminders, simply indicate your choice on the form.

I would prefer appointment reminders by: