SYNERGY ETHERAPY INFORMED CONSENT
(Last updated 3/15/19)
This Synergy eTherapy Informed Consent form is intended to inform you about Synergy eTherapy’s professional services and business policies and to confirm your agreement to the services. By signing this form you, the client, will be acknowledging that you understand and agree that Synergy eTherapy and its provider(s) will provide therapy to you according to this Synergy eTherapy Informed Consent form. The following content must be read, discussed with your therapist at the initial consultation (and any time thereafter as needed), and agreed upon before the client-therapist relationship can begin. Please make sure to read each section carefully. If you have any questions, please discuss them with your therapist before obtaining any eTherapy services.
Synergy eTherapy reserves the right to change the terms of this form and to make any new provisions effective for all protected health information that we maintain. Please feel free to print a copy of this informed consent for your records or we can send you an additional copy if requested. This document is found on the Synergy eTherapy website in several locations including your account dashboard and your consent is gathered during your initial assessment.
PRIVACY & SECURITY OF ETHERAPY SERVICES
de client services to strengthen protections for client data. This includes the companies we use such as the video chat provider, texting app, and email which provide Synergy eTherapy with a BAA to ensure that your PHI is protected according to HIPAA requirements.
Synergy eTherapy may use your PHI for treatment, payment, and eTherapy operations purposes with your consent. You will find more information about your privacy rights in our Notice of Privacy Practices. You have been provided with a copy of that document, and it is posted on our website. Your therapist will discuss it in your initial session. You may reopen the conversation at any time during your work together.
It is our policy to safeguard the privacy of your PHI and records to the fullest extent permitted by law. However, in some circumstances, we may be required to disclose your PHI and/or records to other people even if you have not authorized us to do so. Examples of situations in which we may have to make such disclosures include, but are not limited to:
- If we receive information from you, the client or others indicating that abuse or neglect of a minor or abuse or neglect of a vulnerable adult has occurred, we may have to report that information to a law enforcement agency or to other government entities;
- If the client or another person has communicated to us a threat of violence to the client or to some other potential victim, we may have to inform the potential victim and/or a law enforcement agency of the threat; or
- If, in our judgment, disclosure to a parent or guardian of any treatment given to or needed by a minor client is necessary to prevent serious harm to the health of the minor client.
GOALS, PURPOSES, AND PROCEDURES OF THERAPY
A client-therapist relationship only begins after the user agrees to this informed consent. In general, the goals of therapy include improving and/or maintaining your capacity for healthy thought, feelings and behavior individually, in groups and/or in relationships with others. The purposes of therapy include providing you with a safe and supportive environment in which to a) identify issues and obstacles that may be interfering with healthy thought, feelings and behavior, and b) learn and implement techniques and strategies for making improvements in those areas. However, therapy is not intended as a substitute for your own capacity for thought, feelings or behavior.
The procedures utilized at Synergy eTherapy include prepaid scheduled sessions with a therapist via electronic media (e.g., video conferencing or telephone call) during which you and your therapist will communicate about your mental health status and progress toward the goals established for therapy. Because of legal and ethical requirements, your therapist cannot engage in activities or relationships with you that are not reasonably and necessarily related to therapy.
The specific therapeutic techniques that will be utilized include, but are not necessarily limited to: CBT, Psychodynamic, Mindfulness, Skill Building, Motivational Interviewing, Client-Centered, Family Systems, and Eclectic. Please discuss the specific techniques your Synergy eTherapist might use in your initial intake session. It may be necessary or desirable to change the procedures from time to time during the course of therapy. You will be informed if any changes are recommended and will be given an opportunity to decide whether to continue receiving therapy if the provider considers those changes necessary.
RISKS/BENEFITS ASSOCIATED WITH THERAPY
There are a number of potential risks associated with therapy. For example, in some cases, despite the best efforts of clients and their providers, clients make little or no progress toward their goals. It is possible, though unlikely, that the therapy could adversely affect your health temporarily or permanently. For example, the therapy could lead to recollection, awareness or discovery of events, experiences, conditions or situations that are painful, stressful or unsettling in a variety of ways. The therapy could be financially challenging for you, particularly if the cost of the therapy is not covered by an insurer or some other third party.
However, there are also a number of potential benefits associated with the therapy. For example, you could experience significant improvement in your capacity for healthy thought, feelings and behaviors. You could become aware of other issues or conditions that you want to address as part of the therapy besides those issues or conditions that were initially addressed. Overall, you could experience significant changes and progress in your quality of life as a benefit of the therapy
RISKS ASSOCIATED WITH ETHERAPY
The eTherapy that you will participate in is, in some respects, innovative in nature. In other words, eTherapy has not been used within the professional community for as long or as extensively as other in person methods of providing therapy.
There are always potential security risks associated with electronic communications over the Internet or cell phones as the web and cell phones may not be 100% secure. Synergy eTherapy and each independent eTherapist are committed to working with you, the client, to maintain the confidentiality of your PHI. Here are some tips to help you safeguard your information:
- Use your own personal computer instead of a work computer and create complex passwords to protect email correspondence from being seen by others. Do the same for your cell phone. Pay attention to where you store your cell phone when you are not using it as notifications of emails or texts may pop up where others could see your private information.
- Install a “Firewall” and maintain updated anti-virus protection on your computer.
- You can also create a Hushmail ( http://www.hushmail.com/ ) or other separate email account that you can use just for eTherapy to ensure extra confidentiality and security.
FACTORS AFFECTING DURATION AND RESULTS OF THERAPY
Many factors can impact the duration and results of therapy. They include, for example, your overall health, as well as your mental and emotional health, your motivation to do the work involved in therapy, and external factors related to finances, employment, family, and other circumstances.
ALTERNATIVES TO THE THERAPY
Although the eTherapy that is being offered is considered to be safe and effective, it is possible that alternative services or measures could be at least as safe and effective for you. Other mental health providers, physicians, and non-traditional health specialists, for example, could be beneficial, as could clergy, self-help programs and support groups. If you elect to utilize alternative services or measures in lieu of or in addition to therapy being offered by Synergy eTherapy, your therapist will coordinate care with those other services or measures as much as reasonably possible.
As a client, you have certain rights according to state and federal law regarding the services you receive from Synergy eTherapy. Some of those rights appear in your state’s Bill of Rights. The state in which your Synergy eTherapist is licensed will be able to offer you that state’s Bill of Rights.
- For example, you have the:
- Right to Plan – You have the right to know your treatment options, be a part of your treatment plan, and easily understand information about eTherapy and services provided.
- Right to Respect and Non-Discrimination – You have the right to considerate, respectful care from your therapist that does not discriminate against you.
In addition, you will find more information about your privacy rights in our Notice of Privacy Practices. You have been provided with a copy of that document, and it is posted on our website. Your therapist will discuss it in your initial session. You may reopen the conversation at any time during your work together.
FEES AND BILLING
The fee schedule for eTherapy is as follows: Payment before an eTherapy session by credit card. You may purchase one eTherapy session at a time unless discussed with your eTherapist.
The billing procedure for eTherapy is as follows: Payment before an eTherapy session by credit card. You will have access to your Dashboard in your Account on the Synergy eTherapy website that you can keep for your records along with invoices that are sent directly to your email on file.
Responsibility for payment for Therapy is as follows: Payment is your responsibility. We are a private pay company. You can use an HSA credit card and/or request a Superbill (if appropriate) to submit to your insurance company for partial reimbursement for out-of-network care. There is no guarantee that you will receive any reimbursement from your employer or insurance company and the payment for services is 100% the client’s (or if minor, the minor or parent/guardian’s) responsibility.
Synergy eTherapy offers therapy on an “as needed” basis, which allows you to choose, in consultation with your therapist, how often you want to receive eTherapy. Your appointment times are reserved exclusively for you, so if your scheduled time for eTherapy does not work for you, please contact your therapist directly at least 24 hours before the session start time to reschedule a service already purchased. Otherwise, you may incur a cancellation charge.
We understand that life gets busy! Because of the flexibility of eTherapy services, if you are late to your scheduled session (late means entering your session before it is halfway over), you will receive your service for the remainder of your scheduled session time slot without refund, and it is up to your eTherapist if they have the time to go over your scheduled session time. If you show up after the halfway point of your scheduled session and did not notify your therapist that you will be late, your therapist has the right to reschedule that session and bill it as a “no show.” If you do not show up (e.g., you do not check in for a video chat or answer a phone call for a phone session) at the time of a scheduled session, and you do not contact your therapist within the 24 hour prior cancellation period to let them know you will be late or need to reschedule, the session may also be considered a “no show.” Once a service is purchased and the session becomes a “no show,” you will not receive a refund for that session. If several “no shows” occur, you and your therapist can discuss options for therapy that may work better for you.
QUESTIONS AND COMPLAINTS
If you have a question, comment or complaint about the services you receive from Synergy eTherapy, and you want to communicate with us about that, you may contact Dr. Lisa Herman, Psy.D., Licensed Psychologist and owner of Synergy eTherapy, via telephone at (612) 642-1355 or via email at DrLisa@SynergyEtherapy.com. Also, you have legal rights under state and federal law regarding the services that you receive from Synergy eTherapy. We cannot give you legal advice regarding those rights, so you should consult with an attorney if you have questions about them. In any event, Synergy eTherapy will not retaliate against you for exercising those rights.
ACKNOWLEDGEMENT AND SIGNATURE
By agreeing to this “Informed Consent,” I understand I give permission to use and disclose my protected health information (PHI) for purposes of treatment, payment, and health care operations. Additionally, I agree to the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telehealth and that no information obtained in the use of telehealth, which identifies me, will be disclosed to researchers or other entities beyond the use for treatment, payment, and health care operations without my written consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.
- I understand the alternatives to telehealth consultation as they have been explained to me.
- I understand that telehealth may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.
- I understand that I may expect the anticipated benefits from the use of telehealth in my care, but that no results can be guaranteed or assured.
- I further understand that there are risks unique and specific to Telehealth including, but not limited to, the possibility that our therapy sessions or other communication by my therapist to others regarding my treatment could be disrupted or distorted by technical failures or cout be interrupted or could be accessed by unauthorized persons.
- In addition, I understand that telehealth treatment is different from in-person and that, if my therapist believes I would be better served by another form of psychotherapeutic services, such as in-person treatment, I will be referred to a therapist in my geographic area that can provide such services.
I acknowledge that I have read this form and that I understand it, and that I am agreeing to receive services from Synergy eTherapy according to the policies and procedures described in this form. I understand the risks and benefits of eTherapy, the nature and limits of confidentiality, my privacy, client rights, and what is expected of me as a client of Synergy eTherapy services.
HIPAA NOTICE OF PRIVACY PRACTICES
Your Information. Your Rights. Our Responsibilities.
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
“Protected health information“ (PHI) is information about you, including demographic information, that may identify you or be used to identify you, and that relates to your past, present or future physical or mental health or condition, the provision of health care services, or the past, present or future payment for the provision of health care.
Your Rights Regarding Your PHI
- You have the right to:
- Get a copy of your paper or electronic medical record
- Correct your paper or electronic medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
- You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Include you in a hospital directory
- Provide mental health care
- Market our services and sell your information
- Raise funds
Our Uses and Disclosures
- We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Respond to organ and tissue donation requests
- Work with a medical examiner or funeral director
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us at DrLisa@SynergyEtherapy.com
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/ .
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory (*Note: We do not create or manage a hospital directory.)
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
- In these cases we never share your information unless you give us written permission:
- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
- In the case of fundraising:
- We may contact you for fundraising efforts, but you can tell us not to contact you again.
OUR USES AND DISCLOSURES
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
We can use your health information and share it with other professionals who are treating you.>br> Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Bill for your services
We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html .
Help with public health and safety issues
- We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
We can use or share your information for health research.
Comply with the law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Respond to organ and tissue donation requests
We can share health information about you with organ procurement organizations.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests
- We can use or share health information about you:
- For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court or administrative order, or in response to a subpoena.
- Our Responsibilities
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html .
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website, https://www.synergyetherapy.com .