• Clinician-Patient Services Agreement

  • Clinician-Patient Services Agreement

  • Welcome to Mosaic Psychological Services, LLC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose 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 attached to 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 at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That 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 treating clinician and patient, and the particular problems you are experiencing. There are many different methods the clinician may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor's visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

    Psychotherapy can have benefits and risks. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have many benefits. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But there are no guarantees of what you will experience.

    The first few sessions will involve an evaluation of your needs. By the end of the evaluation, the clinician will be able to offer you some first impressions of what your work together will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with the clinician. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about procedures, they should be discussed whenever they arise. If your doubts persist, Mosaic will be happy to help you set up a meeting with another mental health professional for a second opinion.

    *Please note that psychotherapy services are not intended to serve as a "child custody evaluation." If you intend to initiate therapy services with the expectation of subpoenaing the clinician to testify for custody recommendations you should know that neither the court nor the clinician recognizes this testimony as an official "child custody evaluation." Please consult your attorney to request a court-ordered custody evaluation through the proper channels of the court. Dr. Mullen is available for these specialized evaluations; however, a court order will need to be issued to begin these services.


    Normally, an evaluation will last from 2 to 4 sessions. During this time, both clinicians and patients can both decide if this clinician is the best person to provide the services you need in order to meet your treatment goals. If psychotherapy is begun, one 50-minute session will be scheduled at a time. Often therapy occurs weekly; however, the frequency of sessions will be determined based on treatment goals and the clinical plan to achieve those goals. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 24 hours advance notice of cancellation. It is important to note that insurance companies do not provide reimbursement for canceled sessions.


    Psychological Evaluations are performed to make diagnostic clarifications and to assist in treatment planning. Prior to initiating the psychological evaluation, the clinician may need to clarify the referral question and determine the plan for evaluation, including the review of collateral documents. Payment for the evaluation is to be made in full prior to the release of the psychological report. The clinical opinion and recommendations offered in such a document are based on multiple data sources, document review, testing, interviewing, clinical training, etc. The results of any psychological evaluation are not guaranteed. You may have questions about the findings in the report and it is possible that you may not agree with the clinical opinion offered. It is your right to seek the consultation of another psychologist for a second opinion. Your clinician will be happy to assist you in finding a referral for additional consideration of the referral question.


    The fee for psychotherapy is $150.00 per 50 minutes. In addition to weekly appointments, this fee is assessed for other professional services you may need, though the cost of work for periods of less than one hour may be adjusted or prorated. Other services include report writing, telephone conversations lasting longer than 5 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of me. If you become involved in legal proceedings that require the clinician’s participation, you will be expected to pay for all of the clinician’s professional time, including preparation and transportation costs, even if called to testify by another party. Because of the difficulty of legal involvement, there is a charge of $250 per 60-minutes for sessions and preparation and $250 per hour for attendance at any legal proceeding. Depending on the type of evaluation and the required testing, the fee for a psychological evaluation (note this does not include a court-ordered custody evaluation) including a written report begins at $750.00.


    Due to each clinician’s work schedule, they are often not immediately available by telephone. The clinician does not as a policy return calls between sessions, or interrupt sessions to answer phone calls. The office staff is happy to accept your message and relay it to the clinician in a timely fashion. Each clinician makes 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 the office staff of some times when you will be available. In emergencies, please utilize the local ER and/or 911.


    The law protects the privacy of all communications between a patient and a psychologist/therapist. In most situations, the clinician can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement provides consent for those activities, as follows:

    • Your clinician may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, the clinician makes every effort to avoid revealing the identity of a patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, your clinician will not tell you about these consultations unless they feel that it is important to work together. All consultations will be noted in your Clinical Record (which is called “PHI” in the Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).
    • You should be aware that several mental health professionals work in this practice as well as administrative staff. In most cases, the clinician will need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing, and quality assurance. All of the mental health professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.
    • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
    • If a patient threatens to harm himself/herself, the clinician may be obligated to seek hospitalization for him/her or to contact family members or others who can help provide protection.

    There are some situations where the clinician is permitted or required to disclose information without either your consent or Authorization:

    • If you are involved in a court proceeding and a request is made for information concerning the clinician’s professional services, such information is protected by the psychologist-patient privilege law. I cannot provide any information without your written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.
    • If a government agency is requesting the information for health oversight activities, the clinician may be required to provide it for them.
    • If a patient files a complaint or lawsuit against the clinician, they may disclose relevant information regarding that patient in order to defend themselves.
    • If a patient files a worker’s compensation claim, while under treatment related to the claim, the clinician must, upon appropriate request, furnish copies of all medical reports and bills.

    In an attempt to protect others from harm, there are some situations in which a clinician is legally obligated to take action and reveal some information about a patient’s treatment. These situations are unusual in clinical practice and may include:

    • If I have reason to believe that a child has been abused, the law requires that the licensed clinician file a report with the appropriate governmental agency, usually the Department of Human Resources. Once such a report is filed, the reporting clinician may be required to provide additional information.
    • If there is reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or an elder person, other than by accidental means, or has been neglected or exploited, the clinician must report to an agency designated by the Department of Human Resources. Once such a report is filed, the clinician may be required to provide additional information.
    • If the clinician determines that a patient presents a serious danger of violence to another, the clinician may be required to take protective actions. These actions may include notifying the potential victim, and/or contacting the police, and/or seeking hospitalization for the patient. If such a situation arises, the clinician will make every effort to fully discuss it with you before taking any action and they will limit the disclosure to what is necessary.

    While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important to discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and your clinician is not an attorney. In situations where specific advice is required, formal legal advice may be needed.


    The laws and standards of clinical practice require that Protected Health Information about you be kept in your Clinical Record. Except in unusual circumstances that involve danger to yourself and others or makes reference to another person (unless such other person is a health care provider) and it is believed that access is reasonably likely to cause substantial harm to such other person or where information has been supplied to the clinician confidentially by others, 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 upsetting to untrained readers. For this reason, it is recommended that you initially review them with your clinician, or have them forwarded to another mental health professional so you can discuss the contents. In most situations, there is a copying fee of $1.00 per page (and for certain other expenses). If the clinician refuses your request for access to your records, you have a right of review (except for information provided to me confidentially by others), which will be discussed with you upon request.


    HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that the clinician 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 nor 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; and the right to a paper copy of this Agreement, the attached Notice form, and privacy policies and procedures. Your clinician is happy to discuss any of these rights with you.


    Patients under 18 years of age who are not emancipated and their parents should be aware that the law allows parents to examine their child’s treatment records unless the clinician believes that doing so would endanger the child or it is agreed to act otherwise. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, the clinician will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. The clinician will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s Authorization unless the clinician feels that the child is in danger or is a danger to someone else, in which case, the clinician will notify the parents of their concern. Before giving parents any information, the clinician will discuss the matter with the child, if possible, and do their best to handle any objections he/she may have.


    You will be expected to pay for each session at the time it is held, unless it has been agreed otherwise or unless you have insurance coverage that requires another arrangement. Payment schedules for other professional services will be agreed to when they are requested. Please note that we accept cash, credit card or check. Checks returned for insufficient funds will be assessed a $30.00 fee.

    If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, Mosaic has the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require the clinician to disclose otherwise confidential information. In most collection situations, the only information released regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. Any questions regarding any monthly statement/billing submitted to you must be made in writing within thirty (30) days from the date on the statement; and if you do not do so, you will be deemed to have waived the right to challenge the proprietary and/or the charges made for services and expenses itemized on that statement/billing.


    In order for your clinician 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 health insurance policy, it will usually provide some coverage for mental health treatment. The clinician will fill out forms and provide you with whatever assistance they can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of the service 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. If you have questions about the coverage, call your plan administrator.

    Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While much can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. Some managed-care plans will not allow the clinician to provide services to you once your benefits end. If this is the case, your clinician will do the best they can to find another provider who will help you continue your psychotherapy.

    You should also be aware that your contract with your health insurance company requires that your clinician provide it with information relevant to the services provided to you. The clinician is required to provide a clinical diagnosis. Sometimes they are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, the clinician 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, the clinician 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. Your clinician will provide you with a copy of any report submitted if you request it. By signing this Agreement, you agree that the clinician can provide the requested information to your carrier.

    Once Mosaic has all of the information about your insurance coverage, the patient and clinician will discuss what can we expect to be accomplished 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 clinician services yourself to avoid the problems described above unless prohibited by contract.


    • You have read this agreement
    • You agree to its terms
    • You acknowledge that you have read the HIPAA Notice Form for Georgia described above.
  • Clear
  • Should be Empty: