860-430-1340

HIPAA SERVICE AGREEMENT AND CONSENT FORM

SERVICES OFFERED
We will provide services specifically designed to help you (and/or your minor child), or otherwise provide you with referrals to other professionals. Our clinical and behavioral services consist primarily individual assessments (Clinical and behavioral evaluations), training, in-home and in-school consultation and observations, long-term service provision to youth in the autism spectrum, and short-term consultations with individuals, parents, educators, and other related professionals.
APPOINTMENTS
Except for rare emergencies, we will see you (or your child) at the time scheduled. We understand that circumstances (such as illness or family emergency) may arise which necessitate the occasional cancellation of appointments. In these cases, in order to avoid any misunderstanding, we ask that you speak to us personally and give us as much notice as possible to cancel or reschedule. This will allow us to offer your time to another person. You may be charged the standard hourly rate (see FEES) for appointments not kept or cancelled with less than 48-hours advance notice. Please note that most insurance companies will not reimburse you for missed appointments and you remain responsible for these charges.
PREPARATION FOR ASSESSMENT
It important that individuals be able to perform at their best during Assessment sessions. Please let us know before you arrive (and as soon as possible), if the individual to be tested is not feeling well or is taking any prescribed or over-the-counter medications that we have not been told of in advance. In such cases, Assessment session may need to be rescheduled. Individual should be well rested and should bring snacks for breaks during the Assessment session. Because of the variety of dietary restrictions, we do not offer any food or snacks in our clinic. Parents should plan to remain in the office during Assessment sessions with their minor, unless other (previous) arrangements have been specifically discussed with use and agreed upon with us.
CONFIDENTIALITY, RECORDS, AND RELEASE OF INFORMATION
Clinical services are best provided in an atmosphere of trust. Because trust is so important, all services are confidential, except to the extent that you provide us with written authorization to release specified information to specific individuals, or under other conditions and as mandated by Connecticut, Federal Law and our professional codes of conduct/ethics. These exceptions are discussed below.
TO PROTECT THE CLIENT OR OTHERS FROM HARM
If we have reason to suspect that a minor, elderly, or disable person is being abused, we are required to report this (and any additional information upon request) to the appropriate state agency. If we believe a client is threatening serious harm to him/herself or others, we are required to take protective actions, which could include notifying the police, and intended victim, a minor’s parent(s), or others who could provide protection, or seek appropriate hospitalization.
PROFESSIONAL CONSULTATIONS
Our Practitioners routinely consult about cases with other professionals. In so doing, we make every effort to avoid revealing the identity of our clients, and any consulting professional are also required to refrain from disclosing any information we reveal to them. Unless you object, we do not typically tell clients about these consultations; however, these consultations will be so noted in your Private Health Information. If you want us to talk with, or release information to, other professionals with whom we you are working, you will first need to sign an authorization that specifies what information can be released and with whom it can be shared.
RECORDS
We will review all assessment results during our feedback session and offer you opportunities to review raw Assessment data with us. You will receive a written report that summarizes our findings. This report will include a summary and interpretation of all individual Assessment, as well as impressions from individual observations and consultations conducted as part of a comprehensive individual evaluation. Upon your request, we are happy to provide you with a written summary or our impressions from other meetings, consultations, or observations, as well. We will forward copies of any reports or written summaries to other only with specific, written consent from you. Because of the proprietary nature of Assessment materials, we will release raw Assessment data only to other appropriately credentialed professionals (except as otherwise required by law).
LEGAL PROCEEDINGS
If you are involved in a court proceeding and a request is made for information concerning our professional services, such information is protected by -patient privilege law for our clients, but there is limited protection for information conveyed to others employed by or consulting to Trading Spaces ABA, LCC, under the law. Trading Spaces ABA cannot provide any information without your written authorization, open DCF investigation, National Security investigation, or a court order; however, we may be forced to reveal information. In that case, we will reveal only the minimally acceptable amount of information. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order us to disclose information. Also, if a client files a complaint or lawsuit against anyone affiliated with Trading Spaces ABA, LLC, we may disclose any and all relevant information regarding that client we deem necessary in order to defend ourselves.
PAYMENT FOR SERVICES
It you have a question or objection to fees assessed, objections or inquiries must be made within 90 days of receipt of the relevant invoice, in order to allow review and consideration. Inquiries regarding invoices over 90 days old will be deemed untimely and payment will be expected for those services. If necessary, we may seek assistance from an outside party in order to collect payment for services. In such cases, any disclosures are limited to the minimum that is necessary to achieve the purpose. As you might suspect, the law and professional standards governing these issues are quire complex, and it is important that we discuss any questions or concerns that you (or your minor child) may have at our first meeting, and as they arise in the course of our work together. If any of these types of situations arise, we will make every effort to fully discuss it with you before taking any action and will limit my disclosure to what is necessary. We are not attorneys, however, so you may wish to obtain formal legal consultation if you need specific advice.
WORK WITH MINOR CHILDREN
If a client is under eighteen (18) years of age, the law may provide parents with the right to examine the minor child’s records. Privacy, however, is often crucial to successful progress in treatment and valid evaluation results. If, in the course of an evaluation or consultation, a minor child reveals to use information that he/she does not want shared with his/her parent or guardian, we usually do not reveal such information unless we believe that there is a high risk that the minor will seriously harm him/herself or other; and, in such case, we notify him/her of our intent to notify his/her parent(s) or legal guardian(s).
HEALTH CARE INSURANCE
If we do not file your insurance claims at this time, we will provide you with statements that you may submit to your insurance carrier or complete any forms as required by your insurance carrier in order to obtain reimbursement for out-of-network providers. In order to assist you with obtaining reimbursement for our services, your insurance carrier may require that we provide a clinical diagnosis, or additional clinical information such as treatment plans or summaries, or copies of your child’s entire clinical record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will be stored in a computer. Although all insurance companies claim to keep such information confidential, we have 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. We will provide you with a copy of any report or form that we submit, upon your request. By signing this Service Agreement, you agree that we can provide requested information to your carrier if/when you choose to file a claim for any services that we have provided to you or your child. Also, be advised that many insurance plans do not pay for Clinical and behavioral Assessment or significantly limit the amount of coverage they provide for this kind of service; this is also true for Assessment and therapy services for Autism Spectrum Disorders (or other services judged to be primarily educational in nature). Public school systems, however, administer individual evaluations to school-age children at no cost to you (as governed by local/state educational agency regulations).
PROFESSIONAL RECORDS
You should be aware that, pursuant to HIPAA, we keep clients’ Protected Health Information (PHI) in two sets of professional services. One set constitutes the Clinical Record. It includes information about reasons for seeking our professional services; the impact of any current or ongoing problems or concerns; assessment, consultative, or therapeutic goals; progress toward those goals; a medical, developmental, educational, and social history; treatment history; any treatment records that we receive from other providers; reports of any professional consultations; billing records; releases; and any reports that have been sent to anyone, including statements for your insurance carrier. Except in unusual circumstances that involve danger to yourself or others, or makes reference to another person (unless such other person is a health care provider) and we believe that access is reasonably likely to cause substantial harm to such other person, you or your legal representative may examine and/or receive a copy of your Clinical Record, if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers or may contain information that is protected by federal copyright laws. If we refuse your request for access to your records, you have a right to review (except for information provided to us confidentially by others) which we will discuss with you upon request. In addition, we also keep a set of Personal Notes for most clients to home we provide even a brief or consultative service(s). These notes are for the author’s own use and are designed to assist us in providing you with the best treatment. While contents of Personal Notes vary from client to client, they include references to conversations, Clinical Assessment recording forms, our analysis of those conversations, and the effects of these conversations on my clients. They also may contain particularly sensitive information revealed to us that is not required to be included in the Clinical Record (and information sup plied to us confidentially by others). These Personal Notes are not available to you and cannot be sent to anyone else, including insurance companies. Your signature on this Service Agreement indicates you waive all rights, now and in the future, to accessing this record. Insurance companies cannot require your authorization as a condition of coverage nor penalize you in any way for your refusal to provide authorization.
PATIENT RIGHTS
HIPAA provides you with several new or expanded rights with regards to your Clinical Record and disclosures of PHI. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; having any complaints you make about our policies and procedures recorded in your records; and the right to a paper copy of this Service Agreement, the HIPAA Notice, and our privacy policies and procedures. We are happy to discuss any of these rights with you.
CONTACTING US
Given our many professional commitments, we are often not immediately available by telephone. If you need to leave us a message, we will make every effort to return your call promptly (within 24-48 hours, with the exception of holidays and weekends). If you are difficult to reach, please leave sometimes when you will be available. Because of the nature of the services we usually provide, we do not provide on-call coverage 24-hours per day, 7-days per week. In emergency or crisis situation, please contact your physician, or call 911 and/or go to the nearest hospital emergency room.

Confidentiality & Privacy Policy
The law protects the relationship between a client and a psychotherapist, and information cannot be disclosed without written permission.

Exceptions include:

  • Suspected child abuse or dependent adult or elder abuse, for which I am required by law to report this to the appropriate authorities immediately.
  • If a client is threatening serious bodily harm to another person/s, I must notify the police and inform the intended victim.
  • If a client intends to harm himself or herself, I will make every effort to enlist their cooperation in ensuring their safety. If they do not cooperate, I will take further measures without their permission that are provided to me by law in order to ensure their safety.