At an initial intake appointment to begin therapy services, you will be asked to review and sign paperwork that includes privacy practices, HIPPA (Health Insurance Portability and Accountability Act) information, and a service agreement. Feel free to review the text of these forms below at your convenience.
This notice describes how mental health information about you may be used and disclosed and how you can gain access to that information. Please review this notice carefully. If you are the parent/caregiver of a child that is a patient of mine (Hillary J. Wasson, LCSW), then presume that whenever this notice says "your information," it is pertaining to your child and/ or your family unit.
I, Hillary Wasson, LCSW, know that your mental health information is personal. I will not disclose your information in any unlawful, improper, or unnecessary way. I keep a record of the care and services you receive as required by Illinois Law.
This notice informs you of the ways I may use or disclose your information, as well as your rights and responsibilities pertaining to any possible future disclosure of your mental health information.
The law says I, Hillary J. Wasson, LCSW, must keep any mental health information private if it identifies you in any way. The law also states that I must provide you with this notice that informs you of how your information is kept confidential and the circumstances in which legal duties do not require that I have your consent to disclose. The law requires that I follow this policy.
I am required to disclose your personal information if it could prevent serious threat to the health & safety of yourself, someone else, or the public. I would only disclose this information to people who could help aid in this type of crisis situation (emergency personnel, your family members, etc.). I will, if at all possible, attempt to obtain your consent before disclosing this information. However, if you are a danger to yourself or another person, I am not required to obtain your consent. If I am made aware of child abuse and/or elder abuse, or the abuse of a developmentally disabled person, I am required to notify the proper authorities. I am not required to obtain consent.
You have the right to give me permission to disclose your mental health information by completing the required Release of Information form. If at any time, you decide to revoke this ROI, you may request that I rescind your permission either in writing or verbally during a therapy session. I will then ask you to initial and date the amendment to the ROI stating that you no longer give permission for me to disclose information to whomever the ROI was addressed to.
You have the right to inspect and review your record. You also have the right to request copies; however, a reasonable charge will be added to your account. In rare circumstances, your request to review your record may be denied. I will discuss this with you during our therapy sessions.
You have the right to request a change or amendment to any information you find in your record. To do so, you must write a letter stating the reason you feel your record contains incorrect information and also specifically outlining the change you request. In rare circumstances, your request to amend your record may be denied. I will discuss this with you during our therapy sessions.
You have the right to inform me of your preferred method of communication. If you prefer to only communicate in person, you must attempt to make all scheduled appointments or risk being closed from my services. If you prefer using the phone, you have a right to inform me of any phone numbers you wish to be contacted at (for instance, if you do not want to be contacted at work, etc.) You also have the right to utilize email as a way to communicate with me (see Technological Communication Contract form).
You have the right to request a paper copy of this notice at any time.
If you think your right to privacy has been violated, you have the right to register a complaint with the Secretary of the Department of Health and Human Services. If you feel that your treatment was delivered in an unethical way, you also have a right to register a complaint with the Office of Ethics and Professional Review. Details about this process can be found at: https://www.socialworkers.org/nasw/ethics/rpr.asp.
You have the right to be an active participant in your treatment. Please voice your thoughts, ideas, opinions, & complaints directly to me, Hillary J. Wasson, LCSW. I hope to create an open & comfortable atmosphere where we can have this kind of dialogue without any fear of consequence. If you are unhappy with my services at any time, you have the right to terminate your case. Please notify me when this decision has been made.
Health Insurance Portability and Accountability Act (HIPPA)
- Information from my therapy sessions may be used by Hillary J. Wasson in order to carry out treatment and/or obtain payment. Hillary will obtain signed permission (via a “Release of Information” form) if she feels it is necessary to provide PHI to an outside source.
- There are limitations to this disclosure, which are detailed in more depth in the Notice of Privacy Practice handout provided.
- At all times, I retain the right to revoke this consent. Such revocation must be submitted to Hillary in writing or verbalized clearly during a session.
Service Agreements/Statement of Understanding/Informed Consent
I hereby consent to the use or disclosure of my individually identifiable health information (“Protected Health Information” or PHI), excluding psychotherapy notes, by Hillary J. Wasson, in order to carry out treatment, payment, or health care operations (TPO). My specific authorization must be obtained for disclosure of my PHI, including summary of psychotherapy notes, for purposes other than TPO, except on special situations. I have reviewed the Notice of Privacy Practices for a more complete description of the potential disclosures of such information.
Hillary J. Wasson, LCSW, follows the professional and ethical guidelines outlined by the National Association of Social Workers. She is bound by the legal statutes, guidelines, and licensing/certification requirements of the State of Illinois.
She will not disclose your health information unless expressly authorized by federal and state law. Generally, mental health records may not be disclosed without your authorization, although there are exceptions under federal (HIPPA) and state (e.g., the Illinois Mental Health and Developmental Disabilities Act) law. Such exceptions include routine disclosures to individuals involved in your treatment (e.g., consulting therapists and records custodians) and for payment (billing services, insurance companies and collection agencies), disclosures to her attorneys, legal advisors, and professional insurance liability carrier(s), disclosures to the Inspector General of the Department of Children and Family Services (when relevant to a pending investigation), disclosures pursuant to a court order, and disclosures necessary for her defense in a civil lawsuit filed by you. Additionally, she has a duty to disclose information to the proper authorities where it is believed, based on the exercise of professional discretion, that there is an imminent risk of harm to you or others, or in similar situations such as where abuse or neglect of an elderly person or child is suspected (including but not limited to observations made during home visits). In all such cases, she will seek to ensure the minimum amount of information is disclosed to satisfy the purposes for which it is sought or required.
As part of the business practices for Hillary J. Wasson, LCSW, confidential clinical consultation may occur with either a licensed psychiatrist or psychologist for the purpose of education, staff professional development, and assistance in patient’s ongoing treatment only after patient’s written permission is received.
In case of an emergency, patients are to proceed to the nearest Emergency Room or contact emergency services through 911. In case of a crisis that occurs during business hours, a voice mail message can be left at the office number but if you are in immediate need of assistance, please contact 911 or ERS. Hillary J. Wasson, LCSW, will return these calls as soon as possible. In case of a crisis that occurs after business hours or on weekends or holidays, patients can call ERS - Peoria County at 671-8084 or ERS - Tazewell/ Woodford County at 347-5576. A voicemail can also be left on the office line for Hillary J. Wasson, LCSW, but may not be returned until the next business day, so please utilize the emergency services listed above in case of an emergency.
All fees are required to be paid at the time services are rendered. Only patients with pre-existing contract between their employer or insurance provider and Hillary J. Wasson, LCSW, are exempt from this policy. Patients are responsible for the full payment of fees for services rendered regardless of whether insurance reimbursement will be sought. Hillary J. Wasson, LCSW, will honor contractual agreements made with those managed health care companies which stipulate specific reimbursement restrictions.
All fees are non-refundable and may be increased at any time. However, as a courtesy to her patients, notifications of the increases are typically provided at least 30 days prior to the effective date of the increase in the form of a sign posted in the office of Hillary J. Wasson, LCSW.
The current standard fee schedule is as follows (unless otherwise specified by employer or insurance contract): Initial 90 minute Intake Appointment: $200 (half due to secure appointment)
Follow-up 50 minute therapy session: $150Service Fee/Check returned for Insufficient funds: $30 per check
Home visits: Fees vary depending on location
Appointments may be rescheduled or cancelled without charge up to 48 hours before the original appointment. See Financial Responsibility Policy and Agreement.
11. All psychotherapy patients can request an itemized statement of provided psychological services at any time. The patient retains responsibility for the payment of these charges and for submission of this statement to their insurance provider for allowable reimbursement. Hillary J .Wasson, LCSW, retains no liability in the event of unreimbursed claims. Patient understands and agrees that should monthly or periodic payment arrangements be made, patient is still responsible for the full payment of any unpaid services upon demand.
12. All patients have the right to ask questions, to know the qualifications of their therapist, to understand the techniques and treatment being used, to act or not act upon therapeutic suggestions, and to terminate therapy at any time of their choice. Patients are responsible for any balance due prior to a decision to stop. Hillary J. Wasson, LCSW, retains the professional obligation and right to refer patients to other professional resources as appropriate and to terminate the counseling relationship if it is determined to be in the patients’ best interest. Hillary J. Wasson, LCSW is prohibited from giving patients referral recommendations to a specific provider for any legal or financial concern that requires accessing an attorney for legal advice or financial institution for investment strategies.
13. Hillary J. Wasson, LCSW, may contact patients by phone, email or mail to coordinate scheduling, distribute information about services, forward statements for billing or collection purposes, and to seek a patient’s evaluation of provided therapy services. If the patient is agreeable to using text/email as a form of communication, it is understood that this will be primarily for scheduling/logistical purposes and brief support in-between sessions.
14. It is considered best practice to maintain contact with your therapist through regular appointments at a rate which both the patient and therapist are comfortable with. Therefore, if no appointments have been made after six months, a warning letter will be sent and if no appointments are made within the allotted time, the case will be closed. If the patient is a sliding scale patient and wishes to reopen, then s/he will therefore lose his/her spot and will be required to pay self-pay rates as indicated in the previous page. If the patient is a self pay patient, s/he will be required to pay whatever the new self-pay rates are as indicated in previous page if they wish to reopen therapy services.
15. It is the goal of Hillary J. Wasson, LCSW, to provide patients with meaningful and effective therapy services so that they may receive support, therapy, and consultation towards timely resolution of their personal, relationship, and family concerns. Patients are requested to become actively involved in the therapeutic process, express their thoughts and feelings, and practice what they have learned in their lives outside the therapy office.
I understand and agree to the above statements, policies, procedures, fees, legal, ethical, and professional guidelines, goals, and responsibilities outlined in this Service Agreement/Statement of Understanding/Informed Consent Notice.
I also give my informed consent for psychological treatment for myself and/or my child.
I agree that Hillary J. Wasson, LCSW may contact me by the mailing address provided on the intake form. If I am not comfortable with this, I will discuss it in person with her in session, and provide an alternative address for her to have on file.
I agree to notify Hillary J. Wasson, LCSW, of any change in my personal information (name, address, phone number, email address, household income, insurance information). If I fail to do so, additional charges may apply.
I hereby authorize the release of necessary medical information for insurance reimbursement purposes.
I authorize the payment of medical benefits to the provider of services.
I authorize the release of sufficient information to a collections agency or attorney so that any unpaid fees can be collected.
A copy of this agreement (and any other paperwork) may be provided upon request. The above is subject to the privacy practice policy of Hillary J. Wasson, LCSW, which the undersigned acknowledges has been previously reviewed and a copy is also available upon request. In the event of any inconsistency, the Privacy Practice Policy shall control.
- I have the right to inspect and obtain a copy of my mental health records, although I understand that the provider has the right to deny such request under certain circumstances. I have the right to have the “denial to inspect” reviewed by a “reviewing official.” A reasonable fee may be charged for providing a copy of my records.
- I have the right to request amendments to the information in my mental health record, although I understand the provider has the right to deny such a request.
- I have the right to request an accounting of disclosures of my PHI for purposes other than TPO & those for which I provided authorization. I may submit a written privacy complaint to the U.S. Secretary of the Department of Health & Human Services without any action being taken by the provider against me & without a change in my treatment.
- The provider reserves the right to change the terms of the Notice of Privacy Practices at any time. If the terms are changed, I may obtain a copy of the revisions by requesting a copy.
- I retain the right to request that the provider further restrict how my PHI is used or disclosed to carry out treatment, payment, or health care operations. The provider is not required to agree to such requested restrictions; however, if the provider does agree to the requested restriction(s), such restrictions are then binding on the provider.
- If this agreement is revoked by the patient, the revocation shall be effective except to the extent that the provider has already taken action in reliance on the consent.
- The provider may refuse to treat me if I (or authorized representative) do not sign the consent portion of this form (except to the extent that the provider is required by law to treat individuals). If I (or authorized representative) sign the consent portion and then revoke consent, the provider has the right to refuse to provide further treatment to me as of the time of revocation (except to the extent that the provider is required by law to treat individuals).
By my signature below, I acknowledge that I have reviewed a copy of the Notice of Privacy Practices for Hillary J. Wasson, LCSW and that I am in agreement to the terms listed above regarding HIPPA.