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Sejla Serifovic, Ph.D.
Licensed professional clinical counselor
340 Second Street, Suite 8; Los Altos, CA 94022
Ph: 650.374.7255; [email protected]INFORMED CONSENT AGREEMENT
FOR PSYCHOTHERAPY
When Disclosure Is Required By Law:
When Disclosure May Be Necessary:
Health Insurance & Confidentiality of Records:
E-Mails, Cell Phones, Computers and Faxes:
COSTS, PROFESSIONAL FEES, AND PAYMENTS:
THE PROCESS AND SCOPE OF PRACTICE:
Welcome to my practice. This document (“Agreement”) contains important information about my professional services and business policies, and constitutes your consent for Psychotherapy. This form provides you with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to Health Insurance Portability and Accountability Act (HIPAA) pre-emptive analysis.
HIPAA requires that I provide you with a Notice of Privacy Practices for use and disclosure of PHI for treatment, payment, and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session.
Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have about the procedures. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
All information disclosed within the treatment sessions, and the written records pertaining to those sessions, are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.
When Disclosure Is Required By Law:
o Some of the circumstances where disclosure is required by the law are: 1) where there is a reasonable suspicion of child, dependent or elder abuse or neglect, including but not limited to, physical and sexual abuse; 2) where a client presents a danger to self or to others, including murder, assault, or other physical harm; 3) is gravely disabled; or 4) when client’s family members communicate to Dr. Serifovic that the client presents a danger to others.
When Disclosure May Be Necessary:
o Disclosure may be required pursuant to a legal proceeding by or against you.
- Information discussed in the treatment may be sent to the referring source, and any other individuals/agencies, identified on the Authorization of Release of Health Information signed prior to the treatment.
- You may request a summary of treatment be sent to another person or agency at any time in the future by completing an additional Authorization of Release of Health Information form.
- If you are involved in a court proceeding and a request is made for information about the professional services that I have provided, and/or the records thereof, such information is protected by therapist-client privilege law. I cannot provide any information without your written authorization, a court order, or compulsory process (a subpoena). If you are involved in or contemplating litigation, then you should consult with your attorney to determine, whether a court would be likely to order me to disclose information.
- If an insurance company or other agency is paying the fee for this treatment, then it may be necessary to send a treatment summary to that agency to secure reimbursement. Dr. Serifovic has no control or knowledge over what insurance companies do with the information she submits or who has access to this information. See next point below.
Health Insurance & Confidentiality of Records:
o Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process claims. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies’ computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies’ computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to break in’s and unauthorized access. Medical data has also been reported to be legally accessed by enforcement and other agencies, which may put you in a vulnerable position.
Consultation:
o Dr. Serifovic occasionally finds it helpful to consult other health and mental health professionals about a case; however, client’s identity remains completely anonymous, and confidentiality is fully maintained.
Emergencies:
o If there is an emergency during our work together, or in the future after termination where Dr. Serifovic becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, she may also contact the person whose name you have provided on the biographical sheet.
Litigation Limitation:
o Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc..), neither you nor your attorney, nor anyone else acting on your behalf, will call on Dr. Serifovic to testify in court or at any other proceeding, nor will a disclosure of the records be requested unless otherwise agreed upon.
E-Mails, Cell Phones, Computers and Faxes:
o Please be aware that unauthorized people can access electronic communication, hence, the privacy and confidentiality of such communication can be compromised. Please notify dr. Serifovic, in writing, if you decide to avoid or limit in any way the use of electronic communication. Please do not use e-mail or faxes in emergency situations. Unless you advise dr. Serifovic in writing, she will assume that your signature on this agreement constitutes consent to use e-mail or cell/cordless phone to contact you.
Professional Records:
o The laws and standards of Psychology profession require that dr. Serifovic keeps Protected Health Information (PHI) about you in your Clinical Record. If you have concerns regarding the records, then please discuss them with dr. Serifovic. You have the right to review or receive a summary of your records at any time if you request it in writing, except in limited legal or emergency circumstances, or when dr. Serifovic assesses that releasing such information might be harmful in any way. In such a case, dr. Serifovic will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, upon your written request, dr. Serifovic will release information to any agency/person you specify unless dr. Serifovic assesses that releasing such information might be harmful in any way. When more than one client is involved, such as in cases of family therapy, dr. Serifovic will release records only with the signed authorizations from all the parties (or all those who legally can authorize such a release) involved in the treatment.
In addition, dr. Serifovic may also keep a set of Psychotherapy Notes. These Notes are for her own use and are designed to assist her in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of your conversations, dr. Serifovic’s analysis of those conversations, and how they impact your treatment. Additionally, they can contain particularly sensitive information that you or others shared confidentially. These 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 written, signed Authorization. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide them.
If you need to contact dr. Serifovic between sessions, please leave a message at 650.374.7255. In case of emergency, please call 911 or Emergency Psychiatric Services for your county: Santa Clara 408-885-6100, San Mateo 650-573-2662, Alameda 510-618-3432, Santa Cruz 831-454-4900 or 1-800-952-2335.
Dr Serifovic takes Aetna and United HealthCare insurance. She will process your claim and the remaining cost (your copay) is your responsibility. If you will not be utilizing your insurance, the hourly fee is $250.00 for individual and couples therapy and 300.00 for family therapy.
Forms of Payment:
o Your designated payment type will be used to process payment for all clinical services rendered. The following forms of payment are accepted through dr Serifovic’s practice:
- Visa, MasterCard, and Discover (Credit or Debit).
- Cash & Personal Checks are acceptable as well.
Billing Statements:
o You will receive an insurance-ready billing statement. If you are seeking reimbursement from a healthcare plan privately, you may use this statement to do so. Clients who carry insurance should remember that professional services are rendered and charged to the client and not to the insurance company. Unless agreed upon differently, dr. Serifovic will provide you with a copy of your receipt, which you can then submit to your insurance company for reimbursement, if you so choose. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk, discussed above. Not all issues/conditions/problems that are the focus of psychotherapy are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage.
o If your account is overdue (unpaid) for more than 60 days and there is no written agreement on a payment plan, dr. Serifovic can use legal or other means (courts, collection agencies, etc.) to obtain payment. If such legal action is necessary, its costs will be included in the claim.
Participation in therapy can result in a number of benefits to you, including a better understanding of yourself, improving interpersonal relationships, and resolution of the specific concerns. Working toward these benefits, however, requires effort on your part. Participation in therapy requires your active involvement, honesty, and openness. Dr. Serifovic will ask for your feedback and views, its progress, and other aspects of the evaluation or treatment and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation.
During therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc. Dr. Serifovic does not intend to cause any personal discomfort; she is simply carrying out her professional task associated with therapy session. In therapy, Dr. Serifovic may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel upset, angry, depressed, challenged or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended. Therapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and at times frustrating. There is no guarantee that therapy will yield positive or intended results. During therapy, dr. Serifovic is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you.
A minor has the right to request private data be kept from their parents or legal guardian. Dr. Serifovic will honor this request if it is believed to protect a child from physical or psychological harm, or if confidentiality is in the best interest of the child. However, parents and legal guardians have a right to information regarding their child, and efforts will be made to engage families as partners in treatment services.
Individuals and families have the right to access clinical information. You may request an information review with dr. Serifovic. However, in certain circumstances, if dr. Serifovic determines that reviewing such information may be deemed harmful, she may instead provide a summary of the clinical information. Copies of medical records can be requested at an additional expense.
Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, and parental involvement, is also essential, it is usually dr. Serifovic’s policy to request an agreement with minors (over age 12) and their parents about access to information. This agreement provides that during treatment, dr. Serifovic will provide parents with general information about the progress of the treatment, and the client’s attendance at scheduled sessions. She will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless dr. Serifovic feels that the child is in danger or is a danger to someone else, in which case, she will notify the parents of her concern. Before giving parents any information, dr. Serifovic will discuss the matter with the child, if possible, and do her best to handle any objections she/she may have.
If any child is the subject of a court order, settlement or custody agreement, the parents or guardian MUST furnish dr. Serifovic with a copy of the order or agreement by the parent or guardian who has been awarded or granted legal custody of the child. If two separate or divorced parents share legal custody, or if two guardians are appointed by a court, then all requests for information or all consents for treatment, or a plan for treatment MUST be approved by both parents with legal custody or both by guardians appointed by the courts. The person or party who has obtained or agreed to the custody modification or change shall furnish dr. Serifovic with any modification or change of legal custody or guardianship of the child. A child will NOT be seen unless this information is provided. Any information relevant to the child's treatment learned during a child's treatment may be included in reports and medical records.
The Bay Area at times seems like a small community, and clients may know each other and dr. Serifovic from the community. Consequently, you may bump into someone you know in the waiting room, or into dr. Serifovic out in the community. Dr. Serifovic will never acknowledge working with anyone without his/her written permission. It is your responsibility to communicate to Dr. Serifovic if the relationship becomes uncomfortable for you in any way. Dr. Serifovic will always listen carefully and respond accordingly to your feedback and will discontinue the relationship if she finds it interfering with the effectiveness of therapy, or the welfare of the client, and of course, you can do the same at any time.
Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 hours notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Most insurance companies do not reimburse for missed sessions.
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□ I have read the above agreement and office policies and general information carefully. I understand them and agree to comply with them.
□ I acknowledge that I have received the attached HIPAA Notice of Privacy Form.
□ I acknowledge that I have received a signed copy of this Agreement.
IF CLIENT IS AN ADULT:
____________________________________________
Client Name:
____________________________________________ ___________
Client Signature: (Date)
IF CLIENT IS A CHILD/TEEN/MINOR:
____________________________________________
Child/Teen/Minor Name
_______________________________ __________________________ __________
Parent/Guardian Name: Signature: (Date)
_______________________________ __________________________ __________
Parent/Guardian Name: Signature: (Date)
CLINICIAN:
SEJLA SERIFOVIC, PH.D. LPCC, LMHC
_________________________________________ ___________
(Dr. Serifovic’s Signature)practice policies here.
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