Practice Policies

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#FFFFFF" TEXT="#080000" background="127015b3.jpg"> <div> <FONT SIZE="5" COLOR="#000000" FACE="Arial" ><B>Help4Self   Center</B></FONT><B>    </B><B> |     </B><A HREF="index.htm" TARGET="_top" TITLE="Help4Self Center"><B>home</B></A></div> <div> <A HREF="initial_client_form_for_firs.htm" TARGET="_top" TITLE="Client Information">Client Information</A>   |   <B>Practice Policies</B></div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <A HREF="forms.htm" TARGET="_top" TITLE=" First Visit Forms ">Return to Forms</A></div> </td> <td valign="top" height=390 width="100%" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Practice Policies</I></div> <div> <A HREF="policies.pdf" TARGET="_self" TITLE="policies.pdf">Click here to download</A> and print the policies in a PDF format</div> <bR> <bR> <div> ----------------------------------</div> <DIV ALIGN="LEFT"></DIV> <div> <B>David C. Mathis, Ed.D.</B></div> <div> Licensed Psychologist</div> <bR> <div> <I>Practice Policies</I></div> <bR> <div> As you enter into these services, it is important to me that you are informed about the policies of this practice so that you can make informed choices and so that we can minimize any misunderstandings.  Thus, we are able to enter into a contract for service with the benefit of a mutual understanding about procedures and responsibilities.</div> <bR> <div> <B>Benefits and Risks of Psychotherapy</B></div> <bR> <div> Psychotherapy is not easily reduced to a simple description.  It varies depending upon the personality of both the therapist and the client as well as the particular issues for which the client seeks consultation.  There are a number of different approaches which can be utilized in psychotherapy.  You will be given information regarding the therapies which are being offered. </div> <bR> <div> Individuals contemplating psychotherapy should realize that clients may make significant changes in their lives.  People often modify their behaviors, emotional responses and attitudes during the course of therapy.  In addition, it is possible that people will begin to feel differently about themselves and to otherwise alter significant aspects of their lives.  Clients may make changes in employment, relationships, marriages, or familial relationships.  It is not unusual for clients to feel some discomfort and distress before improvement is felt.  If you have any questions about the process or my approach, we should discuss them if and when they arise.</div> <bR> <div> <B>Confidentiality</B></div> <bR> <div> Tennessee law states: “The confidentiality relationship and communications between licensed psychologist...and client are placed upon the same basis as those provided by law between attorney and client...”  This means that the confidential information is controlled by the client or legal representative.  Therapists have an ethical and moral obligation to keep confidential information which is revealed in sessions.  </div> <bR> <div> There are two exceptions to this law.  First, in the case of an emergency when there is imminent danger to the client or another person, the psychologist can breach the confidentiality.  Second, Tennessee law requires that child abuse be reported to the Department of Children Services.  These situations have rarely arisen in my practice.  Should such a situation occur, I will make every effort to fully discuss it with you before taking any action.  </div> <bR> <div> I may occasionally find it helpful to consult with other professionals.  In these consultations, I make every effort to avoid revealing the identity of my client.  The consultant is, of course, also legally bound to keep the information confidential.  Unless you object, I will not tell you about these consultations unless I feel that it is important for our work together.  </div> <bR> <div> While this written summary of exceptions to confidentiality should prove helpful in informing your about potential problems, it is important that we discuss any questions of concerns which you may have. </div> <bR> <div> <B>Emergency Situations</B></div> <bR> <div> If an emergency arises after normal business hours, you should call 911 or go to the nearest emergency room for assistance.</div> <bR> <div> <B>Financial Considerations</B></div> <bR> <div> You are asking that we enter into relationship for my services.  Just as with any other service provider, whether it be an attorney or an accountant, there are fees for the services that you need.  However, different from many service providers, because many of my services are health services that may be covered under your respective insurance plan, some fees may be paid for by your insurance.  When your insurance pays for the services you will not be billed for any more than what your plan allows.  For example, if your plan reimburses for $80 for a 45 minute psychotherapy session and your portion (co-payment) is $25, then I will accept that amount and you will not have any additional charges for that one service.  </div> <bR> <div> In examining your needs, we will work with together to develop plans based on your needs.  These services will usually include psychotherapy but may also involve assessment and psychological testing.  In addition, you may require additional time for ancillary services such as supplying documents or completing paperwork for employment related needs, e.g., short-term disability, or legal needs, etc.  These services are not covered by insurance plans and will be your responsibility to pay PRIOR to the services being performed.  </div> <bR> <div> The hourly rate for my services are $125.00 per hour.  Time that is spent in ancillary services will be billed on 15 minute increments.  It is normally my practice to charge for other professional services you may require such as (1) assessment reports, correspondence, telephone conversations, (2) attendance at meetings, (3) preparation of records or treatment summaries for special requests, or (4) any extra services that you may request.  I am also available for telephone appointments but these cannot be billed to your insurance.  </div> <bR> <div> Routinely, prior to the second visit, an assessment visit is needed.  The use of personality inventories or other types of psychological testing is important in assessment and treatment planning.  Fees for these tests range from $40 to $95, depending upon the tests that are selected.  In most instances, charges for these psychological tests are billed separately to you and are not billed to your insurance due to additional case management requirements, authorization forms and procedures.</div> <div> In unusual circumstances, you may become involved in litigation which may require my participation.  You will be expected to pay for my professional time even if I am compelled to testify by another party.  Because of the complexity of legal involvement, I charge on a different rate for preparation for and attendance at any legal proceeding.  </div> <bR> <div> <B>Cancellations</B></div> <bR> <div> Each appointment is a reservation of time specifically for you.  My regular session fee is charged for appointment canceled without a 24 hour notice.  This fee is your responsibility and cannot be charged to insurance.  </div> <bR> <div> <B>Managed Care and Privacy</B></div> <bR> <div> The escalation of cost of health care has resulted in an increasing level of complexity about insurance benefits.  Managed care plans often require advance authorization for behavioral health services.  These plans often promote a short term treatment approach designed to resolve specific problems which may not be the most conducive to addressing your specific needs.  </div> <bR> <div> You should also be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes additional clinical information such as a treatment plan or summary.  This information is part of the insurance company’s records and some of it is stored in a computerized database.  Privately paying for services is another means of protecting your privacy and affording you the freedom to disclose information that is needed to ensure that you obtain the best possible service.</div> <bR> <div> I adhere to the statues of the State of Tennessee, the Ethical Principles of Psychologists and the Ethical Principles of the American Psychological Association.  Client records are my responsibility and are securely maintained to protect confidentiality.</div> <bR> <div> <B>You signature below indicates that you agree to abide by these terms of our professional contract.</B></div> <bR> <bR> <bR> <div> _____________________     _______________________</div> <div> Signature of client     Responsible party (if other than client)</div> <bR> <bR> <div> <B>I agree to pay for appointments that are missed when not canceled with a 24 hour notice.</B></div> <bR> <bR> <bR> <div> _____________________     _______________________</div> <div> Signature of client     Date</div> <bR> </td> </tr></table></body>