9419 Common Brook Road Suite 208

Owings Mills, MD 21117

Tel: (410) 864-0211

Fax: (410) 618-4163

info@myiHEAL.com

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© 2019 Institute for HEALing, LLC

Informed Consent

Welcome to the Institute for HEALing, LLC (hereafter known as “iHEAL”). This document contains important information about the professional services and business policies of iHEAL. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

 

WELLNESS SERVICES

Wellness is the state of being healthy. iHEAL provides treatment services to help patients achieve their optimal level of health. Treatment is a relationship between people that works in part because of clearly defined rights and responsibilities held by each person. As a patient in treatment, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights of which you should be aware. Your treatment provider at iHEAL has corresponding responsibilities to you. These rights and responsibilities are described in the sections below.

 

iHEAL employs different types of treatment providers with varying levels of education and licensure. All employees who are not fully licensed are supervised by a fully-licensed professional.

 

CONFIDENTIALITY

iHEAL’s policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document, and we have discussed those issues. Please remember that you may reopen the conversation at any time during treatment.

 

Therapists at iHEAL work as a clinical team. The clinical team is comprised of a team leader and/or other therapists. They often consult with each other about cases to offer the highest level of care. However, private information like your name will not be shared in consultation with the clinical team. Only pertinent information for the purposes of consultation and treatment planning will be shared. Every member of the clinical team is bound to the same confidentiality standards as your therapist.

 

Because some iHEAL therapists are still working toward full licensure, they will be working with a professional who is fully-licensed. Your therapist may share details about your case with his/her clinical supervisor in order to provide you with the highest level of care. The clinical supervisor is bound to the same confidentiality standards as your therapist. That is, your confidential and private information may be shared between the therapist and clinical supervisor, but not others.

 

In the same vein, therapists who are still in training may need to video or audio record psychological sessions. Sessions are recorded for the purposes of training the therapist solely. Recordings are typically digital and will be destroyed every three (3) weeks if not sooner.  

PSYCHOTHERAPY SERVICES

iHEAL offers psychotherapy for individuals, couples, families, and groups. Psychotherapy has both benefits and risks. Benefits may include a release of emotional turmoil and psychological distress, increased and more effective coping skills/strategies, a deeper understanding of self and others, resolution to specific problems, greater awareness and insight into long-standing problems, and better life satisfaction to name a few.

 

Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life.  Note that these uncomfortable feelings are a part of the therapeutic process, and psychotherapy has been shown to have benefits for individuals, couples, and groups who undertake it. 

 

Unfortunately, there are no guarantees about what will happen.  Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on things we discuss outside of sessions.

 

The first 1-4 sessions will involve a comprehensive evaluation of your needs. By the end of the evaluation, you will get information about what might be causing the problems that you articulate. You will also get information from your therapist that will clearly highlight treatment recommendations, what treatment might look like, and how often it should be.

 

Together with your therapist, you will create a treatment plan that outlines your goals for our work. This is your treatment, so you have much input in how and when we proceed as long as we are moving in a healthy direction. Should you decide that you want a second opinion, we would be happy to assist you in finding another treatment center or therapist.

 

PSYCHOLOGICAL TESTING

iHEAL offers testing for learning disabilities, learning giftedness, test anxiety, and ADHD. Benefits associated with psychological testing include knowing your academic/educational strengths and weaknesses, getting an official diagnosis of a disability, receiving recommendations to enhance academic/educational/professional strengths and mitigate academic/educational/professional weaknesses; and receiving accommodations at work or school for a disability. Risks include test fatigue during and after the testing session(s).

 

Testing can take many hours depending on the patient’s processing and working speed. Your examiner will adjust the layout of the testing session to ensure that you are able to perform your best.

 

APPOINTMENTS
Appointments vary based on the type of service that you will need. These specifics will be discussed when you talk about treatment recommendations with your therapist.

 

The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session, we ask that you provide with 24 hours’ notice. If you miss a session without canceling, or cancel with less than 24-hour notice, you will be charged a $40 cancellation fee (unless the therapist agrees that the circumstances that led to you not providing cancellation notice were beyond your control).

 

It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the portion of the fee as described above. If the treatment schedule allows, we would be more than happy to accommodate you during that same week. However, that may not always be possible. In addition, you are responsible for coming to your session on time. If you are late, your appointment will still need to end on time.

If you miss three (3) sessions out of six (6) scheduled appointments, your treatment may be ended. Keeping patients on a therapist’s caseload who are not being seen presents a professional risk for the therapist and the practice.

 

PROFESSIONAL FEES

With all treatment services, you are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check or credit card. Returned checks are subject to an additional fee of up to $35.00 to cover the bank fee that iHEAL incurs.

 

Our collection agency is Omni Credit Management, Inc. They may be used to secure your balance if you refuse to pay your medical bill. A collection fee of 35% of the total bill will be charged if your account goes to collections. They may be contacted at (410) 489-6900.

Other Services: iHEAL would be more than willing to provide other professional services such as telephone calls and documentation, so long as they require less than 15 minutes. Any professional services that require longer than 15 minutes may be subject to a prorated fee.

 

Other professional services may include work and/or academic consultations, court appearances, attendance at meetings, and detailed documentation (outside of an individual psychological evaluation). Know that you may have to waive your right to confidentiality if you want the therapist to present clinical findings on your behalf in court or during other hearings/meetings. Lastly, if your court case requires the participation of an iHEAL representative, you will be expected to pay for the professional time at the hourly individual therapy rate even if another party compels a representative of iHEAL to testify. You should discuss these services in detail with your therapist so that you know what to expect of him/her.

 

INSURANCE
In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. iHEAL is credentialed with some insurance companies. Please discuss insurance plans and co-pays with your therapist. We use independent billing companies, Office Ally and Theranest, to bill for treatment services. These companies, which use secure billing programs, will keep track of your treatment costs and bills.

 

If we don’t accept your insurance plan, but you have out-of-network benefits, you can still use your health insurance coverage to get treatment. After each session, you can receive a superbill, which provides proof of service and payment of your visit. It documents all of the information that your insurance company needs in order to reimburse you for all or most of your treatment costs.

 

You should also be aware that, in order to be reimbursed for your treatment costs, most insurance companies require a diagnosis. Sometimes additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases) is requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, iHEAL has no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. iHEAL will provide you with a copy of any documentation that we submit on your behalf, if you request it. By signing this Agreement, you agree that we can provide requested information to your insurance carrier if you plan to be reimbursed for your treatment.

 

Some insurance companies have a deductible, which is an out-of-pocket amount that must be paid by the patient before the insurance companies are willing to begin reimbursing for treatment. This will typically mean that you will be responsible for paying for 100% treatment until your deductible has been met. Additionally, some insurance companies require that the deductible limits be met each year, which means that you may need to pay 100% of treatment at the start of each calendar year.

 

PROFESSIONAL RECORDS

We are required by law and industry practice to keep appropriate records of the psychological services that we provide. Your records are maintained in a secure location in the office. Records include information like your reasons for seeking therapy, the goals and progress we set for treatment, your diagnosis, topics we discuss, your histories (medical, social, educational, psychological, legal, trauma, treatment, and substance abuse), records we receive from other providers, and your billing history. Except in unusual circumstances that involve danger to yourself, you have the right to a copy of your file. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers.  For this reason, it is recommended that you initially review them with your iHEAL therapist, or have them forwarded to another mental health professional to discuss the contents. If your request for access to your records is denied, you have a right an explanation for the denial and seek legal counsel to obtain your record. You also have the right to have a copy of your file be made available to any other health care provider at your written request. There may be copying and filing fees depending on the extent of your request.

 

PARENTS & MINORS

While privacy in therapy is crucial to successful progress, parental involvement can also be essential. iHEAL only sees children 6-17 years old. Additionally, an assent agreement may be signed between the patient (depending on the patient's age) and the parents/guardians allowing iHEAL to share general information about treatment progress and attendance as well as a treatment summary upon completion of therapy. All other communication will require the patient’s agreement, unless there is a safety concern (see also above CONFIDENTIALITY section for exceptions), in which case iHEAL will make every effort to notify the patient of the necessity to disclose information ahead of time.

 

CONTACT US

The iHEAL treatment team is not always immediately available by telephone because we are treating other patients. At these times, you may leave a message on iHEAL’s confidential voicemail and your call will be returned as soon as possible. If you are in the middle of a medical emergency, please do not wait for a return phone call from your therapist at iHEAL. Instead, please go to your local hospital emergency room or call 911.

 

Your therapist will make every attempt to inform you in advance of planned absences and discuss plans during his/her absence if necessary.

 

OTHER RIGHTS

If you are unhappy with what is happening in therapy, please discuss your dissatisfaction with your therapist so that s/he can respond to your concerns. Such comments will be taken seriously and handled with care and respect.

 

You may also request that your therapist refer you to another therapy at iHEAL or a different treatment agency as you are free to end therapy at any time. You have the right to considerate, safe, and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, immigrant status, national origin, or any other cultural identity factor. You have the right to ask questions about any aspects of therapy and about specific academic and clinical training and experience of your therapist.