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Terms and Policy

Social media policy
Due to professional ethical standards and to avoid virtual relationships between the client and therapist that could be potentially confusing or harmful, it is the policy of RCPS that employees, independent contractors, volunteers or interns will not engage in social media relationships with current therapy clients. As a result, "friend" requests or similar social media requests by clients will not be accepted.
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Client Services Agreement

Renaissance Counseling and Psychological Specialists, PLLC

Client Services Agreement

This document serves as the basis for a formal agreement between you as a client/patient and Renaissance Counseling and Psychological Specialists (hereafter referred to as RCPS). It is important for you to understand this agreement so please read this document in its entirety and ask your counselor/therapist about anything that is unclear to you. You will be asked to indicate that you have read, understand, and accept the terms of this agreement. Doing so will also indicate that RCPS has informed you of our privacy practices and your rights under the Health Insurance Portability and Accountability Act (HIPAA).

For more information on HIPAA, please see the Client Rights section below or ask for a copy of the Notice of Privacy Practices (the Notice) for use and disclosure of protected health information (PHI) for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail. The law requires that we obtain your acknowledgement that we have provided you with this information.

You can discuss any questions you have about this agreement with your RCPS therapist. You may also revoke this agreement in writing at any time. Revocation of the agreement will terminate the relationship between you and RCPS but will not affect any action RCPS has already taken based on the previous agreement. Terminating the agreement also does not prevent RCPS from providing information necessary to collect insurance payments for services provided prior to our receiving your revocation or otherwise pursuing collection of fees you owe RCPS for services previously delivered.

Counseling and Psychological Services

1. Counseling and psychological services are provided by Terry A. Casey, Ph.D., Licensed Psychologist, HSP or his associates.

2. Although research shows that in most cases clients benefit from high quality counseling/therapy, as with any type of treatment or intervention, there can be no guarantees of outcomes or what you will experience.

3. Counseling/therapy or psychological services can have both benefits and risks. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. However, since therapy often involves discussing unpleasant aspects of one’s life, clients may experience uncomfortable feelings like sadness, guilt, anger and frustration. If you receive a diagnosis of a mental health disorder, it can carry with it a social stigma; it may affect your ability to acquire life or health insurance in the future; or it may interfere with certain job opportunities.

4. Counseling/psychotherapy is not like a medical doctor visit. Instead, it requires very active participation on the part of the client.

Office Hours and Appointments

The secure client portal should be checked to determine available appointment times. Unless otherwise agree upon appointments are normally a 45 - 50 minute “hour.” Once an appointment is scheduled, clients are expected to pay for the appointment unless notice of cancellation is provided through the client portal at least 24 hours in advance of the appointment time. Unlike a traditional medical office, client appointments at RCPS reserve a specific hour for the client to meet with his/her therapist. Since no other clients are waiting in line to be seen during this time period a no-show or late cancellation of an appointment wastes an hour during which another client could be served. As a result, services may be terminated for clients who miss or late-cancel multiple appointments.

Professional Fees

Usual & customary fees. RCPS charges $150 for intake interviews and $130 for 45 - 50 minute sessions thereafter. In some cases you may be charged a pro-rated fee for sessions or other professional services of less than 45 minutes such as reporting of test results, telephone conversations, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of your RCPS therapist.

Testing fees. Psychological testing or other types of assessment is often useful during the course of counseling. These tests are discussed prior to administration and fees are based on the amount of time necessary for face-to-face administration, interpretation of scores and written or verbal reporting of results. Hourly testing fees are equivalent to the fee established for regular counseling sessions with your therapist (full fee/sliding scale) but have a minimum fee of $130 per hour.

Legal matters. Be aware that RCPS therapists are not specialists in Forensic Psychology or other areas related to legal matters. RCPS recommends that specialists in these areas be sought for this type of work. Because of the difficulties typically associated with legal involvement, should your RCPS therapist be involved in any legal proceedings the charge will be $250 per hour for preparation and attendance at any legal proceeding on your behalf.

Billing and Payment

You will be expected to pay for services at the time services are provided or prepay. Payment by personal check is preferred until credit card payment process is set up. (Note: Credit card payment option coming soon but as of 5/8/2016 are not yet available.) Outstanding balances will be billed monthly. RCPS reserves the right to turn delinquent accounts over to a collection agency in order to collect unpaid balances. In most collection situations, the only information that would be released regarding a client’s treatment is his/her name, the nature of services provided, and the amount due. If such action is necessary, its costs will be included in the claim. There will be a $35.00 fee for returned checks.

Insurance Reimbursement

RCPS providers are not currently members of insurance provider networks and does not accept payments for from insurance companies. Clients whose insurance benefits include out-of-network coverage may in some cases be able to file an out-of-network claim with the insurance company. In these cases, RCPS will provide the basic information needed to file the claim but RCPS cannot guarantee payment by your particular insurance plan.

Further, clients should be aware that even when they have mental or behavioral health insurance coverage, actual payment for services is contingent upon a number of specifics. For example, a client may not have received a diagnosis that meets the policy’s “medical necessity criteria” or the policy’s deductible may have not been met. Clients are strongly encouraged to consult with their insurance company before attempting to file a claim for services provided by an out-of-network provider.

Contacting Your Therapist

Emergencies. If you have a mental health related emergency contact the Metro Crisis Line (615-244-7444).

E-mail. E-mail communications may be made only through the secure client portal.

Client Rights

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that provides new privacy protections and patient/client rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA gives you the right to:
• request that your therapist amend your record
• request restrictions on what information from your Clinical Record is disclosed to others
• request an accounting of most disclosures of PHI that you have neither consented to nor authorized
• determine the location to which protected information disclosures have been sent
• have any complaints you make about the therapist’s policies and procedures recorded in your records
• a paper copy of this Agreement, the HIPAA Notice form, and RCPS’s privacy policies and procedures and to discuss any questions you may have about these rights with your RCPS therapist.

Understanding Confidentiality and its Limits

The law protects the privacy of communications between a client and psychologist and most other mental health professionals. Except as otherwise indicated in this document, your therapist may only release information about your treatment to others if you sign a written Authorization form that meets HIPAA requirements. Three types of exceptions are listed below.

1. Situations in which your RCPS therapist is obligated to take actions which he/she believes are necessary to attempt to protect the client or others from harm. These include the following:

Child abuse. If your RCPS therapist has reason to believe that someone under 18 years of age has been injured as a result of brutality, abuse or neglect or has been sexually abused, the law requires that report be made to Child Protective Services or another appropriate governmental agency. Once such a report is filed, the therapist may be required to provide additional information.
Abuse of a vulnerable adult. If your RCPS therapist has reason to suspect that an adult who is physically or mentally vulnerable has suffered abuse, neglect or exploitation, the law requires that the therapist report to the Department of Human Services. Once such a report is filed, the therapist may be required to provide additional information.
Client’s threat to harm another. If a client has communicated an actual threat of bodily harm against a clearly identified victim, and the RCPS therapist believes that the client has the ability and likelihood of carrying out the threat, then the therapist is required to take reasonable steps to protect the victim, including notifying the potential victim, contacting law enforcement officials, and/or seeking involuntary hospitalization for the client.
Client’s threat to harm self. If a client is deemed to be an immediate threat of harm to self, the RCPS therapist may be obligated to seek hospitalization for him/her, or to contact family members or others (including law enforcement) who can help provide protection.

2. Situations in which your RCPS therapist is permitted or required by law to disclose information without either your consent or authorization. These include the following:

Court proceedings. If you are involved in a court proceeding and a request is made for information concerning the professional services provided to you by RCPS, such information is usually protected by the psychotherapist-client privilege law. In most cases, RCPS cannot provide any information without either (1) your written Authorization or (2) a valid court order. If you are involved in or are contemplating litigation, you should consult with an attorney to determine if a court would be likely to order RCPS to disclose information.

Health oversight activities. If a government agency is requesting the information for health oversight activities (e.g., issues such as communicable diseases), RCPS may be required to provide it to them in certain circumstances.

Lawsuits. If a client files a complaint or lawsuit against RCPS or his/her RCPS therapist, RCPS may disclose relevant information regarding that client in order to defend the therapist or the organization.

Worker’s compensation. If a client files a worker’s compensation claim RCPS must, upon appropriate request, provide a report to the appropriate individuals, including the client’s employer.

Reporting data on physical abuse. As of July 1st, 2007 Tennessee law requires mental health professionals to make monthly reports regarding knowledge of physical abuse to adults for statistical use by the State. This information does not include names of clients, victims, or perpetrators.

3. Situations that require only that you provide written, advance consent as indicated by your signature on the Acknowledgement form. These include the following:

Consulting with professionals. Your RCPS therapist may consult with your current or past health/mental health professionals or other clinical staff at RCPS. All health-related professionals are bound to keep your information confidential within the limits of the law. Consultations will typically be noted in your Clinical Record (see the Professional Records section below).

Handling of PHI by RCPS staff. All RCPS support staff are bound by the same rules of confidentiality as your therapist. They have received training about protecting your privacy and have agreed not to release any information outside of RCPS without the permission of a professional staff member.

Contact with PHI by RCPS’s Business Associates. As required by HIPAA, RCPS maintains formal contracts with its Business Associates (e.g., answering service, cleaning service, etc.) in which the individual or business/organization promises to maintain the confidentiality of PHI of RCPS clients except as specifically allowed in the contract or otherwise required by law. If you wish, you can be provided with the names of these individuals, businesses, and organizations and/or a blank copy of the Business Associate contract.

If any of the above situations in #1, #2, or #3 above should arise, the RCPS therapist will, if possible, make every effort to fully discuss it with you before taking any action and will limit the disclosure to only what is necessary. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that you discuss any questions or concerns that you may have now or in the future with your RCPS therapist. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.

Professional Records

You should be aware that, under HIPAA regulations, your RCPS therapist may store Protected Health Information (PHI) about you in two sets of professional records. One set constitutes your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that were received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone.

Generally you may review and/or receive a copy or summary of your Clinical Record if you request it in writing. However, because these are professional records, they can be easily misinterpreted and/or be potentially upsetting to untrained readers. For this reason, RCPS recommends that you initially review them in the presence of your therapist, or have them forwarded to another qualified mental health professional with whom you can discuss the contents. As allowed by law, RCPS charges a retrieval/copying fee of 15¢ for the first five pages of a record and 25¢ per page thereafter.

In circumstances where RCPS feels that your review or receipt of your Clinical Record may result in a danger to yourself or another or when disclosure of your record compromises the privacy of another person, RCPS may deny your request. If your request for access to your Clinical Record is refused, you have a right of review, which your therapist will discuss with you upon request. The exceptions to this policy are contained in the Notice form.

In addition to your Clinical Record, your therapist may also keep a set of Psychotherapy Notes for his/her own use designed to assist him/her in providing you with the best treatment. These may include more detailed content of your conversations with the therapist, his/her analysis of those conversations, and how they impact your therapy. They also contain particularly sensitive information that you may reveal to the therapist that is not required to be included in your Clinical Record. Also included may be information from others provided to the therapist confidentially. Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes are not available to you and cannot be sent to anyone else, including insurance companies, without your signed Authorization.

Minors and Parents/Guardians

Clients who are minors often need the same privacy and confidentiality in counseling as do adults. RCPS therapists make every effort to maintain necessary privacy in their therapeutic relationships with minor-age clients while keeping parents or guardians appropriately informed about the child’s condition and progress. If the parents of a minor-age client are estranged/divorced it is RCPS policy that a copy of the court-decreed parenting agreement be on file. Parents should be aware that even non-custodial parents usually have the right to access their child’s Clinical Record. Parents should also be aware that the state of Tennessee allows 16 and 17 year olds to seek psychotherapy without their parents’ consent if they are sufficiently mature to understand and make judgments about the risks and benefits of such treatments. In these cases, parents do not necessarily have access to their older adolescent child’s records. It is, however, RCPS’s policy to seek an agreement with the teen on general information (e.g., reports of progress & attendance) that may be shared with the parents in a way that will allow parental involvement while still safeguarding the adolescent’s privacy. Except where the law allows otherwise (e.g., danger to self or others), any other communication from the therapist to a parent will require the minor client’s written authorization.
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HIPAA Notice
Clinicians’ Policies and Practices to Protect the Privacy of Your Health Information


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

Renaissance Counseling & Psychological Specialists, PLLC (hereafter, RCPS) clinicians and their support staff 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” refers to information in your health record that could identify you.

• “Clinician” refers to any mental health professional who provides clinical services. At RCPS this includes both psychiatry staff and psychotherapists/counselors.

• “Treatment, Payment and Health Care Operations”

– Treatment is when your RCPS clinician provides, coordinates or manages your health care and other services related to your health care. An example of treatment would be when the clinician consults with another health care provider, such as your family physician or another mental health professional.

– Payment is when RCPS obtains reimbursement for your healthcare. An example of payment is when your clinician discloses 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 the RCPS office practices. 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 RCPS such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.

• “Disclosure” applies to activities outside of RCPS such as releasing, transferring, or providing access to information about you to other parties.

• “Consent” means that you give prior permission. You give RCPS consent to handle your PHI as outlined in this Notice when you sign the Patient Acknowledgement form.

II. Uses and Disclosures Requiring Authorization

Your RCPS clinician 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 instances when your clinician is asked for information for purposes outside of treatment, payment and health care operations, the clinician will obtain an authorization from you before releasing this information. The clinician will also need to obtain an authorization before releasing your psychotherapy notes. “Psychotherapy notes” are notes the clinician has made about conversations with you during a private, group, joint, or family counseling session, which have been 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) the clinician has 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. Uses and Disclosures with Neither Consent nor Authorization

Your RCPS clinician may use or disclose PHI without your consent or authorization in the following circumstances:

• Child abuse: If the clinician has knowledge of any child who is suffering from or has sustained any wound, injury, or disability, or physical or mental condition of such a nature as to reasonably indicate that it has been caused by brutality, abuse, or neglect, the clinician is required by law to report such harm immediately to Tennessee Child Protective Services or to the judge having juvenile jurisdiction, or to the office of the sheriff or the chief law enforcement official of the municipality where the child resides. Also, if the clinician has reasonable cause to suspect that a child has been sexually abused, the clinician must report such information, regardless of whether the child has sustained any injury.

• Adult and domestic abuse: If the clinician has reasonable cause to suspect that an adult who is vulnerable physically, mentally, or emotionally has suffered abuse, neglect, or exploitation, the clinician is required by law to report such information to the Tennessee Department of Human Services.

• Health oversight: If a complaint is filed against the clinician with the Tennessee Board of Examiners in Psychology (or other appropriate state Board of Examiners), the Board has the authority to subpoena confidential mental health information from me relevant to that complaint.

• Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about the professional services that an RCPS clinician has provided you and/or the records thereof, such information is privileged under state law, and the clinician must not release this information without your written authorization or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. The RCPS clinician must inform you in advance if this is the case.

• Serious threat to health or safety: If you communicate to your clinician an actual threat of bodily harm against a clearly identified victim, and the clinician has determined or reasonably should have determined that you have the apparent ability to commit such an act and are likely to carry out the threat unless prevented from doing so, the clinician is required to take reasonable care to predict, warn of, or take precautions to protect the identified victim from your violent behavior.

• Workers' compensation: If you file a worker's compensation claim, and the clinician is seeing you for treatment relevant to that claim, the clinician must, upon request, furnish to your employer or insurer, and to you, a complete report as to the claimed injury, the effect upon you, the prescribed treatment, and estimate of duration of hospitalization, if any, and a statement of charges.

IV. Patient's Rights and Clinician’s Duties

Patient’s Rights:

• Right to Request Restrictions You have the right to request restrictions on certain uses and disclosures of PHI about you. However, the RCPS clinician is not required to agree to a restriction that 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 a clinician. Upon your request, your bills will be sent to another address.)

• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in RCPS’s mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, the RCPS clinician will discuss with you the details of the request 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. The clinician may deny your request. On your request, the clinician 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 regarding you. On your request, the clinician 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 RCPS upon request, even if you have agreed to receive the notice electronically.
Clinician’s Duties:

• RCPS is required by law to maintain the privacy of PHI and to provide you with a notice of its legal duties and privacy practices with respect to PHI.

• RCPS reserves the right to change the privacy policies and practices described in this notice. Unless RCPS notifies you of such changes, however, RCPS is required to abide by the terms currently in effect.

• If RCPS revises its policies and procedures, RCPS will notify you by mail, phone, fax, or e-mail.

V. Questions and Complaints

If you have questions about this notice, disagree with a decision an RCPS clinician makes about access to your records, or have other concerns about your privacy rights, you may contact the RCPS Privacy Officer at 615-781-3000.

If you believe that your privacy rights have been violated and wish to file a complaint with the RCPS office, you may send your written complaint to Privacy Officer, RCPS, 321 Billingsly Court, Suite 20, Franklin, TN 37067. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. RCPS’s Privacy Officer can provide you with the appropriate address upon request.

You have specific rights under the Privacy Rule. RCPS will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date and Changes to Privacy Policy

This notice will go into effect on April 14, 2003.

RCPS reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI maintained by RCPS. RCPS will notify you by mail, phone, fax, or e-mail of the revision of notice and make the revised notice available any of its offices. If needed, RCPS will also provide a revised notice by mail, e-mail, or fax. Additionally, the notice will be made available on RCPS’s website (
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