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Edward Jacobs, Ph.D. & Associates 12 Parmenter
Road Londonderry, NH
03053 ---------------------- (603) 437-2069
OFFICE POLICIES AND CONSENT TO TREATMENT AGREEMENT
These
policies have been established to make psychological services as effective as possible, to minimize the possibility of any
misunderstanding, and to comply with certain legal requirements. Please read this thoroughly, and discuss
any questions with me.
License and Code of Ethics
I am a New Hampshire Licensed Psychologist (Edward Jacobs,
Ph.D., Richard Shulik, Ph.D.) ◊ Independent Clinical Social Worker (Vicki Jacobs,
MSW, Madeleine Mandelbaum, MSW) ◊ Clinical Mental Health Counselor (Danielle Viola,
M.A., Robert Mattia, M.Ed., CAGS), governed by the Code of Ethics of the American Psychological Association
(Edward Jacobs, Ph.D., Richard Shulik, Ph.D.) ◊ National Association of Social Workers
(Vicki Jacobs, MSW, Madeleine Mandelbaum, MSW) ◊ American Counseling Association
(Danielle Viola, M.A., Robert Mattia, M.Ed., CAGS). My license, or a current copy
of it, is displayed in these offices. A copy of my professional Code of Ethics is available
in these offices for you to review at your request.
Qualifications and Scope of Practice
I
received my graduate degree in the year 1981 (E. Jacobs), 1979 (R. Shulik), 1981 (V. Jacobs), 1983 (M. Mandelbaum), 1991 (R.
Mattia), 1999 (D. Viola). My practice is a general mental health practice that includes counseling, psychotherapy, and
assessments with children, adolescents, adults, families and groups, as well as consultation with agencies, organizations,
and other professionals on mental health matters. There might also be times when I testify in court as
an expert witness. Psychologists also have training and experience in psychological testing.
Neurofeedback training is part of thepractice of Edward Jacobs, Ph.D., RIchard Shulik, Ph.D. and Danielle Viola, M.A.
Patients’ Rights
A copy of the Mental Health Bill of Rights is posted in the waiting area or,
if you are seen outside of the main office, will be provided to you.
Confidentiality
Nature and Limits:
Communication between you and me, as your psychotherapist, is confidential,
and will not be revealed to any other person or agency without your permission, unless under certain special circumstances.
In order to obtain your permission to release confidential information, I will ask for your permission in writing to
release information to a specified person or agency. That permission will have a time limit to it, and
may be revoked at any time by you.
Recognizing the benefit of second opinions, I may occasionally consult with a colleague about my work,
always protecting the identities of my clients.
There
are also certain situations in which I would be legally or ethically required to reveal information obtained during therapy
to other persons and/or agencies without your permission. These situations are as follows:
1) If you communicate "a serious threat of physical violence against a clearly identified or reasonably identifiable
victim or victims" or property, I am required by law to warn the intended victim(s) or the police,
or to obtain civil commitment of you to the state mental health system; 2) If you indicate a danger of
hurting yourself and refuse to accept further appropriate treatment, I may call your family, agencies, or other individuals
who, in my opinion, would assist in protecting your safety; 3) If I have any reason to suspect that a child
or incapacitated adult has been abused or neglected, I am required to report this to the appropriate state
authority; 4) If I am aware of the existence of certain occupationally related illnesses, communicable
diseases, or critical health problems, I must report this to the appropriate state agency. The law prohibits
me , except under very limited circumstances, to disclose the identity of a person tested for the HIV virus; 5)
If you are involved in a civil commitment proceeding, in pursuing a personal injury action, or in filing a workers'
compensation claim, or if my conduct is being reviewed by licensing authorities, your privileged communication may be waived;
6) If I am issued a court order to provide information, I will be required to comply with that order;
7) If you have a serious or chronic mental illness, a person living with or providing care to you
may be provided information concerning diagnosis, admission to or discharge from a treatment facility, functional assessment,
prescribed medications and side effects, manifestations of the failure to take medications, treatment plans and goals, and
behavior management strategies; 8) If you are subject to an involuntary emergency psychiatric
admission, I might be required to provide information essential to your care; 9) If
your treatment is related to an injury from a gunshot wound or other serious injury suspected to be caused by a criminal act,
I might be required to inform a law enforcement official.
Third Party Billing:
If you give me permission to bill a third party for my services, I will release
information to that party necessary for the processing of that claim. If you choose to use your insurance
coverage for my services, most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes
additional clinical information such as a treatment plan or goals, or a summary, or copies of reports, or in some cases, a
copy of the entire record. This information will become part of the insurance company files and some of
it will probably be computerized.
Electronic Communications:
Sometimes information might be exchanged
between myself, my clients, or other entities that is transmitted electronically, such as in the form of faxes, emails or
electronic billing information. I will make every effort to safeguard the confidentiality of this information.
Information that is sent by me will only contain the minimal necessary information to accomplish its purpose.
Information that is received by me will be placed in your chart. Since computers can maintain information
on their hard drives even when files have been deleted, and since I have no control over the way in which other persons or organizations
use or store the information that they send to or receive from me. I cannot guarantee the confidentiality of this information.
If you do not consent to electronic communications, please inform me immediately, before beginning treatment, so I
can determine how to proceed.
Length of Appointments
I will normally make 45 minutes available for your appointment from the scheduled
start of your appointment time. At times I may elect to extend the length of the appointment.
I may also, by mutual consent, agree to meet for briefer periods of time. I am normally available
to you during our scheduled appointment times.
Emergency Procedures
If you need to reach me in an emergency, you can call my answering service
(644-6232) at any time and ask them to try to contact me. The answering service will try to reach me, and
when they do reach me, I will attempt to return your call as soon as possible. PLEASE NOTE:
If you choose to set up your telephone line so it will not accept blocked calls, I might not be able to reach
you in an emergency if I am out of the office, since the telephones that I use outside the office might have blocked numbers.
I go about my normal routine during evenings and weekends, and I am out of the office at various times
during the week. Since I do not carry a beeper, and may be unreachable immediately at times, there may
be times when it will take me several hours to return your call.
If you or your family feel that there is an emergency or impending crisis and I cannot be reached soon
enough, contact or go to your nearest hospital's emergency room for assistance.
Recommended Treatment
After evaluating your situation, I will discuss with you my clinical impressions,
and my recommendations for treatment, and decide with you which services are appropriate.
Length of Treatment:
The length of treatment varies according to the needs of each individual client.
In many instances, a client's goals can be accomplished with short-term treatment. In other situations,
it may be desired by the client or recommended by me, that treatment proceed over a longer period of time. It is important to understand the limits of your insurance coverage and your
own financial resources so you can make an informed decision about the affordability of treatment. Many
reimbursement plans are oriented towards a short-term treatment approach, which is often appropriate. However,
if a length of treatment is desired by you that is longer than your insurance company approves, it is important to understand
what your financial obligations will be.
Benefits and Risks:
Obtaining psychological services, such as counseling or psychotherapy,
can have benefits and risks. Since participation in these services often involve discussing unpleasant
aspects of your life, you might experience uncomfortable feelings like sadness, anger, guilt, anxiety, anger, frustration,
loneliness and helplessness. On the other hand, obtaining psychological services has also been shown to
have benefits for people. It can lead to better understanding of oneself, better relationships, solutions
to specific problems, and significant reductions in feelings of distress.
Neurofeedback
training also can have benefits and risks. Since we are working with the ability of the nervous system to
regulate attention and emotional control, an individual might respond with feelings of anxiety, sadness, too much energy,
too little energy, an excess of emotional expression, a decrease in emotional expression, or changes in sleep.
These effects tend to be temporary and, if they occur, need to be communicated as soon as possible to your therapist
so corrections in the training can be made. The benefits of neurofeedback can include improved attention,
improved processing of information, and improved emotional stability and control.
Psychological testing can be used to evaluate your intellectual, cognitive, emotional
and personality functioning. The benefits include obtaining information about yourself or your child about
strengths and vulnerabilities, which can also help you plan for personal, educational, vocational, psychological and parenting
matters. Testing can also elicit feelings of sadness or anxiety, from finding out about problems about
which one was unaware, or confirming problems that one suspected were there. In addition, psychological
testing is often sought out or used for specific purposes, such as informing decisions regarding child custody, educational
planning, or eligibility for benefits. The results might not support the outcome that you wish, and you
might experience anger or disappointment.
It is important to understand that the tester must base his or her conclusions
on the information contained in the tests, the patient’s history and demeanor, and the tester’s clinical judgment,
rather than on a need to please the patient or obtain a certain outcome. It is our policy to change the content of our psychological
testing reports only under rare circumstances, such as to correct factual errors, further clarify clinical impressions, or
protect someone from serious harm.
Records
Maintenance of Records:
I maintain a file for each client. The file includes information
related to intake, diagnosis, treatment plan, billing, consent to treatment, treatment notes, and any other written or electronic
information I received from or about the client. Treatment notes include the date of each session and might
include information about facts or issues discussed, and treatment recommendations. The client is entitled
to a copy of the records for a fee which covers copying and administrative costs. The client can also see
a copy of the records. If you wish to review a copy of your record, I recommend that you review it with me
so we can discuss its contents.
Release of Records:
I am able to release your records, or any part of them, with your written
permission, provided you pay for any reasonable copying or administrative costs in advance. Furthermore as
a condition of hiring our services, you agree that records or reports will not be released to you or other parties if you
have an outstanding balance in your account with the practice.
Caretaking of Records in the Case of Incapacity;
In the event of the incapacity or death
of a clinician in this practice, your records will be managed by either Edward Jacobs, Ph.D. or Vicki Jacobs, MSW.
Minors
The
treatment of a minor must be authorized by a parent or guardian (with limited exceptions). In the treatment
of minors, parents (even non-custodial parents) have the right to access and authorize release of information.
In order for me to be effective in working with a minor, however, the minor needs to have some degree of privacy in
order to trust me and to talk about what the most important concerns.
Therefore,
if you are a parent of a minor who is receiving services from me, you agree that the information that I reveal to you about
the minor will be limited to information necessary to preserve the safety of the minor and others, and information that, in
my opinion, will help you to be helpful to the minor in the context of your relationship with him or her. You
agree that it will be at my discretion to reveal specific content from my meetings with the minor.
Couples
Treatment records of couple’s sessions contain sensitive information
about each person. Therefore, in the case of couples treatment, whether the members of the couple are married
to each other, unmarried, separated or divorced, both members of the couple agree that records will only be released by joint
consent. In the event of a disagreement, the records will not be released without a court order.
Group Therapy
Unlike individual treatment, group therapy is not protected by law. Client
concerns about confidentiality should be discussed prior to beginning treatment.
Professional Boundaries and Sexual Misconduct
Licensed psychotherapists are obligated to establish and maintain appropriate
professional boundaries (relationships) with present and past clients and their family members.
Sexual relations by a mental health professional with a client or a former
client (a person who was given psychotherapy within two years prior to sexual relations with the psychotherapist) is considered
sexual misconduct and is subject to disciplinary action.
Billing and Insurance Coverage
Fees:
My billing rate is $185 for initial appointments, $165 per 45 minute session,
and $165 per 45 min for related work. Related work includes, but is not limited to, telephone consultations;
my attendance at meetings on your behalf, with your consent, including travel time; review of records or files; and the preparation
and writing of reports. Neurofeedback fees are: $300 per initial two hour evaluation, and $95 per half-hour
training session. In cases of unusual financial hardship, I may be willing to negotiate a reduction in fee or an installment
payment plan.
Payment for services is due at the time of service or, in the case of related
work, upon the receipt of a bill for my services. At times, I require pre-payment for my services.
Insurance Billing:
Under certain circumstances, I may agree to bill your insurance directly for
my services, with the exception of related work and missed appointments (see below), which are generally not covered by insurance
benefits. If your insurance or other third party is billed for my services, you are still ultimately
responsible for payment of all fees, unless there are exceptions to this provision in my contract with the insurance company
or third party. As stated earlier, it is important to understand the limits of your insurance coverage
and your own financial resources so you can make an informed decision about the affordability of treatment.
As a client, you agree to an insurance waiver stipulating that any fees that
are not paid by your insurance company within 90 days of billing will be billed directly to you, and that you will be responsible
for payment of the claim.
You are responsible for finding out exactly what services your insurance policy
covers, including deductibles, copayments and coverage limitations. Many insurance companies and managed
care plans also require advance authorization before they will provide reimbursement for services. You
are responsible for finding out the services that have been authorized, the number of sessions or hours, the time limitations,
and the authorization number which is necessary for billing. It is your responsibility to keep current
with this information so you know when your authorized coverage will expire. If you do not find out or
provide the information which is required of you, you agree to be fully responsible for payment of my full fee for these services.
In addition to the “related work and missed appointments,” that
are stated above, there are other services that I might provide that either might not covered by, for which I
will not bill to your insurance company. These services include, but are not limited to, neurofeedback
training and some types of psychological testing. The lack of insurance reimbursement available for these
services will be discussed with you, when appropriate. In order to receive these services, you agree to
waive insurance billing and to pay for them directly.
Monthly Statements and Payment:
If you have a balance due, or if you
request it, you will be provided with a monthly statement of your account. All outstanding balances are
due upon receipt of the statement, unless another arrangement has been agreed upon. You agree to
have unpaid balances billed to your credit card if other payment arrangements cannot be made.
For checks that are returned to us for insufficient funds, you will be assessed
a returned check fee of up to $25.
Unpaid Balances
If you are having some difficulty making payment because of your financial
situation, it is important to let me know immediately so we can work out some plan or timetable for payment that will be manageable
for you. As long as you communicate with me about your situation, I am confident that we can work out a
reasonable arrangement for payment.
If your account is more than sixty (60) days in arrears, and suitable arrangements
for payment have not been agreed to, I reserve the option of referring your account to a collection agency or an attorney
to pursue collection of the unpaid balance. If such action is necessary, the costs of bringing that action
or securing that collection will be billed to you, which will be an additional 35% of the balance.
If an outstanding balance remains in your account after you have left therapy,
I will make a reasonable effort to contact you, usually by mail, to arrange payment. If you are unable
to pay your balance in full at that time, I will be happy to work out a payment plan with you at your request.
However, if after reasonable efforts to collect from you have failed, I reserve the option of referring your account
to a collection agency or an attorney to pursue collection of the unpaid balance, and to bill you for the costs of bringing
that action or securing payment.
Payments can be made with Visa and Mastercard.
Missed Appointments
Appointment times are reserved for you to the exclusion of anyone else.
If you cancel or miss your appointment time, for any reason, you will be billed directly for my full fee, not the fee
that I might have contracted for with your insurance company, which only pertains to services which I provide that is covered
by the insurance company. This fee cannot be billed to your insurance or other third parties.
Your signature indicates your agreement with this policy.
Charging for missed appointments is not intended to be punitive.
My income depends on my being able to use my available time. I have promised that hour to you and,
if it is not used by you, and I cannot make use of it, I cannot make it up.
I
try to be as flexible as possible with this policy and, therefore, there are certain exceptions. You will
not be charged for a missed appointment: 1) If you cancel your appointment ahead of time and we can reschedule
your appointment during the same calendar week; 2) If you cancel ahead of time and I can fill the time
by scheduling another client in that time. If you cancel and cannot reschedule, I will make every effort
to fill the time with another client; 3) If you are taking a vacation and inform me at least several weeks
in advance; 4) If you or your child is ill and this illness prevents your attendance at our session.
Complaints
and Privacy Inquiries
Reports of professional misconduct should be directed to the New Hampshire
Board of Mental Health Practice, 49 Donovan Street, Concord, NH 03301, 603 271-6762.
Complaints regarding the privacy of confidential information, the policies
and procedures of this practice, or professional behavior within this practice, can be made by contacting, by telephone or
in writing: Edward Jacobs, Ph.D. at extension 10.
Edward Jacobs,
Ph.D. & Associates
__________________________________________ (Name of Patient)
CONSENT TO TREATMENT
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I have received and read, and understand and agree to, the OFFICE POLICIES AND CONSENT TO TREATMENT AGREEMENT of Edward Jacobs,
Ph.D. & Associates, have had the opportunity to ask questions, and agree to receive services from the practice.
I consent to my protected health information being used by Edward Jacobs, Ph.D. & Associates to provide psychological services,
and to maintain health care operations. I understand that this complete document, including the signature page, is available
for my review online at www.jacobsassociates.org and at the office of Edward Jacobs, Ph.D. & Associates.
Signature and Date:_____________________________________________________________
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INSURANCE WAIVER
• I authorize and agree to pay for any services that I receive,
including consultations, report writing, document review and preparation, and travel time that have not been authorized by
my health insurance, including the following: _______________________________________________________________________________.
INDEMNIFICATION
• I agree to indemnify and hold harmless Edward Jacobs, Ph.D. & Associates and any
of its employees or consultants for any use made of its evaluations, reports or records by any third party.
RELEASE OF INFORMATION
• I
authorize the release of protected health information, both verbal and written, from Edward Jacobs, Ph.D. & Associates,
to my/my child's primary care physician,
__________________________ of ___________________________________ related to
my mental health and health concerns.
• I
authorize the release of any medical or other information necessary to process health insurance claims.
•
I authorize payment of medical benefits to Edward Jacobs, Ph.D. & Associates , 12 Parmenter Road, Londonderry,
NH 03053, for services rendered.
• I authorize
the release of information to the Insurance Commissioners of the States of New Hampshire and Massachusetts related to claims
for services that are billed to my insurance that are not processed accurately.
•
I authorize Edward Jacobs, Ph.D. & Associates to bill any outstanding patient balance each month to the credit
card indicated below.
Signature and Date: _______________________________________________
Visa/Mastercard
#:
Name on card:
Expiration date:
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