Dr. Piper Glasier, MSW,
License #LCS 20600
25301 Cabot Road, Suite
Laguna Hills, CA 92653
P.O. Box 6262
Laguna Niguel, CA 92607
Business Phone: 949-443-2222
Cell phone for texting:
PSYCHOTHERAPIST- PATIENT SERVICES
HIPAA AGREEMENT – CALIFORNIA
Welcome to my practice. This document (the Agreement) contains
important information about the Health Insurance Portability and Accountability
Act (HIPAA), a federal law that provides privacy protections and patient rights
with regard to the use and disclosure of your Protected Health Information
(PHI) used for the purposes of treatment, payment, and health care operations. HIPAA requires that I provide you with a
Notice of Privacy Practices (the Notice) for use and disclosure of PHI for
treatment, payment, and health care operations. The Notice, which is part of 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. It is
important that you read through this information 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 or in the course of discussion between us. This 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.
Psychotherapy is not easily described in general
statements. It varies depending on
the personalities of the psychotherapist and patient, and the particular
problems you are experiencing.
There are many different methods I may use to deal with the problems you
hope to address. Psychotherapy
calls for a very active effort on your part. In order for therapy to be most
successful, you will have to work on things we talk about both during sessions
and between sessions. Psychotherapy
can have benefits and risks. Since
therapy involves discussing unpleasant aspects of your life, you may experience
uncomfortable feelings like sadness, guilt, anger, frustration, loneliness,
loss, and helplessness. On the
other hand, psychotherapy has been shown to have many benefits. Therapy often leads to better
relationships, solutions to specific problems, and a significant reduction in
feelings of distress. There are no
guarantees of what you will experience.
Sessions are 45 minutes in length. One hour sessions are available, as well
as double sessions. Often clients
opt to come more than once a week so the work can reach a deeper level more
quickly, and themes can remain open and built upon the next session without
having to wait a full week.
Cancellation of Session
I consider the time I schedule for you, whether it
is one time per week or multiple times per week, as a "lease" of my time. I reserve this time specifically for
you. If you cannot make it to the
session (whether due to illness, any type of emergency, or any other reason),
and we cannot reschedule a time during the same week, I will charge you for the
missed session. The exception to
this is if you give me at least two weeks notice of an upcoming vacation. In this case, I will not charge you for
the missed session(s).
Payment is to be made by cash, check, or credit
card at the time of the appointment.
I would appreciate it if you make out your check before the session
begins in order to maximize your valuable session time. Insurance is the responsibility of each
patient. You will receive a statement
at the end of each session from the previous session, which is acceptable for
submission by most insurance companies.
My 45 minute session fee is listed on my website.
Full hour sessions as well as double sessions are available. In addition to
session time, I charge this amount for other professional services you may
need, though I will proportion the cost if I work for periods of more or less
than one session. Other services
include report writing, telephone sessions, consulting with other professionals
with your permission, preparation of records or treatment summaries, and the
time spent performing any other services that you may request of me that I
agree to perform. If you become
involved in legal proceedings that require my participation, you will be
expected to pay for all of my professional time, including preparation and
transportation costs, even if I am called to testify by another party. Because of the difficulty of legal
involvement and the potential disruption to my schedule, I may charge a
proportionately higher per hour fee for preparation and attendance at any legal
proceeding. I generally do not agree
to be involved in legal proceedings if it is left to my choice.
Due to my work schedule, I am often not immediately
available by telephone. You may
leave a message on my voice mail, at: 949-443-2222 or at my email address: firstname.lastname@example.org, or by leaving me a text on my cell phone: 949-292-0725, all of which I
monitor frequently. I will make
every effort to return your call on the same day you make it, with the
exception of weekends and holidays.
If you are difficult to reach, please inform me of some times when you
will be available. If you are
unable to reach me and feel that you cannot wait for me to return your call,
contact your family physician or the nearest emergency room and ask for the
psychotherapist or psychiatrist on call.
If I will be unavailable for an extended time, I will provide you with
the name of a colleague to contact, if necessary, on my business telephone:
Billing and Payments
You will be expected to pay for each session at the
time of each session, unless we agree otherwise. Payment schedules for other
professional services will be agreed to when they are requested. In
circumstances of unusual financial hardship, I may be willing to negotiate a
fee adjustment. We will also agree
to periodic review of raising your fee with regard to changes in your
circumstances and/or cost of living adjustment.
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. If you
have a "PPO" health insurance policy, it will usually provide some coverage for
mental health treatment. You will
be responsible for billing your own insurance. I will respond to requests from
your insurance company only after discussing it with you. I will provide you with whatever
assistance I can in helping you receive the benefits to which you are entitled;
however, you (not your insurance company) are responsible for full payment of
my fees. It is very important that
you find out exactly what mental health services your insurance policy covers.
You should carefully read the section in your insurance coverage booklet that
describes mental health services. I will generally be considered an
"out-of-network" provider. If you have questions about the coverage, call your
You should also be aware that your contract with
your health insurance company may require that I provide it with information
relevant to the services I provide you.
I am required to provide a clinical diagnosis. Sometimes I am required to provide
additional clinical information such as treatment plans or summaries, or copies
of your entire Clinical Record. Before I can disclose this information, both
you and I must receive written notification from the insurer stating what they
are requesting, why they are requesting it, how long it will be kept, and what
will be done with the information when they are finished with it. In such situations, I 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 probably
be stored in a computer. Though all
insurance companies claim to keep such information confidential, I 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. I
will provide you with a copy of any reports I submit, if you request it. By signing this Agreement, you agree
that I can provide requested information to your insurance carrier.
Once we have all the information about your
insurance coverage, we will discuss what we can expect to accomplish with the
benefits that are available and what will happen if they run out before you
feel ready to end your sessions. It
is important to remember that you always have the right to pay for my services
yourself to avoid problems described above.
Limits on Confidentiality
The law protects the privacy of all communications
between a patient and a psychotherapist.
In most situations, I can only release information about your treatment
to others if you sign a written authorization form that meets certain legal
requirements imposed by state law and/or HIPAA. But, there are some situations where I
am permitted or required by law to disclose information without either your
consent or authorization:
I may occasionally find it helpful to consult with other health and
mental health professionals about a case.
During a consultation, I make every effort to avoid revealing the
identity of my patient. The other
professionals are also legally bound to keep the information confidential. If you don't object, I will not tell you
about these consultations unless it is important to our work together. I will note all consultations in your clinical
If a patient threatens to harm him/herself, I may be obligated to seek
hospitalization for him/her, or to contact family members or others who can
help provide protection.
If you are involved in a court proceeding and a request is made for
information about the professional services that I have provided you and/or the
records thereof, such information is protected by psychotherapist-patient
privilege law. I cannot provide any
information without your (or your legally-appointed representative's) written
authorization, a court order, or compulsory process (a subpoena) or discovery
request from another party to the court proceeding where that party has given
you proper notice (when required), has stated valid legal grounds for obtaining
PHI, and I do not have grounds for objecting under state law (or you have
instructed me not to object). If
you are involved in contemplating litigation, you should consult with your
attorney to determine whether a court would be likely to order me to disclose
If a government agency is requesting the information for health
oversight activities pursuant to their legal authority, I may be required to
provide it for them.
If a patient files a complaint or lawsuit against me, I may disclose
relevant information regarding that patient in order to defend myself.
If a patient files a worker's compensation claim, I must, upon
appropriate request, disclose information relevant to the claimant's condition,
to the worker's compensation insurer.
There are some situations in which I am legally
obligated to take actions, which I believe are necessary to attempt to protect
others from harm and I may have to reveal some information about a patient's
If I have knowledge of a child under 18 or I reasonably suspect that a
child under 18 that I have observed has been the victim of child abuse or
neglect, the law requires that I file a report with the appropriate
governmental agency. I also may
make a report if I know or reasonably suspect that mental suffering has been
inflicted on a child or that his or her emotional well being is endangered in
any other way (other than physical or sexual abuse, or neglect). Once such a report is filed, I may be
required to provide additional information.
If I observe or have knowledge of an incident that reasonably appears to
be physical abuse, abandonment, abduction, isolation, financial abuse or
neglect of an elder or dependent adult, or if an elder or dependent adult
credibly reports that he or she has experienced behavior including an act or
omission constituting physical abuse, abandonment, abduction, isolation, financial
abuse, or neglect, or reasonably suspects that abuse, the law requires that I
report to the appropriate government agency. Once such a report is filed, I may be
required to provide additional information.
If a patient communicates a serious threat of physical violence against
an identifiable victim, I must take protective actions, including notifying the
potential victim and contacting the police. I may also seek hospitalization of the
patient, or contact others who can assist in protecting the victim.
If I have reasonable cause to believe that the patient is in such mental
or emotional condition as to be dangerous to him or herself, I may be obligated
to take protective action, including seeking hospitalization or contacting
family members or others who can help provide protection. If such a situation arises, I will make
every effort to fully discuss it with you before taking any action and I will
limit my disclosure to what is necessary.
While this summary of exceptions to confidentiality
should prove helpful in informing you about potential problems, it is important
that we discuss any questions or concerns that you may have now or in the
future. The laws governing
confidentiality can be quite complex, and I am not an attorney. In situations where specific advice is
required, formal legal advice may be needed.
You should be aware that, pursuant to HIPAA, I keep
Protected Health Information (PHI) about you in two sets of professional
records. One set constitutes your
Clinical Record. It includes
minimal information about your reasons for seeking therapy, your diagnosis, the
goals that we have set for your treatment, your progress toward these goals,
brief pertinent medical, social, and treatment history, plus any past treatment
records that I receive from other providers, reports of any professional
consultations, your billing records, and any reports that have been sent to
anyone, including reports to your insurance carrier. Except in unusual circumstances if that
disclosure would physically endanger you and/or others or makes reference to
another person (unless such other person is a health care provider), you 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 might be upsetting to
untrained readers. For this reason,
I recommend that you initially review them in my presence, or have them
forwarded to another mental health professional so you can discuss the
In addition, I also keep a set of Psychotherapy
Notes. These are for my own use and
are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy
Notes vary from patient to patient, they can include the contents of our
conversations, my analysis of those conversations, and how they impact your
therapy. They also contain
particularly sensitive information that you may reveal to me that is not
required to be included in your Clinical Record. These Psychotherapy Notes are kept
separate from your Clinical Record. Psychotherapy Notes are not available to
you and cannot be sent to anyone else, including insurance companies.
HIPAA provides you with several new or expanded
rights with regard to your Clinical Records and disclosures of protected health
information. These rights include
requesting that I amend your record; requesting restrictions on what
information from your Clinical Record is disclosed to others; requesting an
accounting of most disclosures of protected health information that you have
neither consented to or authorized; determining the location to which protected
information disclosures are sent; having any complaints you make about my
policies and procedures recorded in your records; the right to a paper copy of
this Agreement, the attached Notice form, and my privacy policies and
procedures; the right to breach notification including what happened and what
you can do to protect yourself. I
am happy to discuss any of these rights with you.
As a social worker licensed in this state and as a
member of the National Association of Social Workers, it is my practice to
adhere to more stringent privacy requirements for disclosures without an
authorization. The following addresses
these categories to the extent consistent with the NASW and Code of Ethics and
or Neglect: I may disclose your PHI to
a state or local agency that is authorized by law to receive reports of child
abuse or neglect.
Administrative Proceedings: I may disclose your PHI
pursuant to a subpoena (with your written consent), court order, administrative
order or similar process.
Patients: I may disclose PHI
regarding deceased patients as mandated by state law, or to a family member
that was involved in your care or payment for care prior to death, based on
your prior consent. A release of
information regarding deceased patients may be limited to an executor or
administrator of a deceased person's estate or the person identified as
next-of-kin. PHI of persons that
have been deceased for more than fifty (50) years is not protected under HIPAA.
Emergencies: I may use or disclose your
PHI in a medical emergency situation to medical personnel only in order to
prevent serious harm. I will try to
provide you a copy of this notice as soon as reasonably practical after the
resolution of the emergency.
Involvement in Care: I may disclose information
to a close family member or friends directly involved in your treatment based
on your consent or as necessary to prevent serious harm.
Oversight: If required, I may
disclose PHI to a health oversight agency for activities authorized by law,
such as audits, investigations, and inspections. Oversight agencies seeking this
information include government agencies and organizations that provide
financial assistance to the program (such as third-party payors based on your
prior consent) and peer review organizations performing utilization and quality
Enforcement: I may disclose PHI to a
law enforcement official as required by law, in compliance with a subpoena
(with your written consent), court order, administrative order or similar
document, for the purpose of identifying a suspect, material witness or missing
person, in connection with the victim of a crime, in connection with a deceased
person, in connection with the reporting of a crime in an emergency, or in
connection with a crime on the premises.
Government Functions: If you are in the
military, I may have to use or disclose your PHI to for national security
purposes, including protecting the President of the United States or conducting
Health: If required, I may use or
disclose your PHI for mandatory public health activities to a public health
authority authorized by law to collect or receive such information for the
purpose of preventing or controlling disease, injury, or disability, or if
directed by a public health authority, to a government agency that is
collaborating with that public health authority.
Safety: I may disclose your PHI if
necessary to prevent or lessen a serious imminent threat to the health or
safety of a person or the public.
If information is disclosed to prevent or lessen a serious threat it
will be disclosed to a person or persons reasonably able to prevent or lessen
the threat, including the target of the threat.
Research: PHI may only be disclosed after a special
approval process or with your authorization.
Permission: I may also use or disclose
your information to family members that are directly involved in your treatment
with your verbal permission.
Authorization: Uses and disclosures not
specifically permitted by applicable law will be made only with your written
authorization, which may be revoked at any time, except to the extent that we
have already made a use or disclosure based upon your authorization.
If you believe I have violated your privacy rights,
you have the right to file a complaint in writing to my office at: 25301 Cabot
Road, Suite 216, Laguna Hills, CA 92653 or with the Secretary of Health and
Human Services at: 200 Independence Avenue, S.W. Washington, D.C. 20201 or by
calling 202-619-0257. I will not
retaliate against you for filing a complaint.