Information, Agreements & Consent
HIPAA Notice of Privacy Practices
| Client Rights
| Information, Agreements & Consent
Length of Treatment
In general, the number of sessions you will require depends on the type of problem(s) that will be addressed. Our goal is to provide to provide successful treatment in the least number of sessions possible.
Appointments will be scheduled at a time mutually acceptable to both you and your therapist. 24-hour advance notice of cancellations is required except in cases of emergency. Appointments missed or canceled with less than 24 hours notice will be charged the usual rate.
IN HOME SERVICES
If services are being provided in your home, please show respect for the therapist and refrain from smoking during sessions. If anyone in your household has any airborne illnesses (i.e. flu, colds, etc.), please notify the therapist with at least 24 hours notice. Depending on traffic and weather conditions, your therapist may be fifteen minutes early or late for your appointment; your understanding is appreciated.
The fee for psychotherapy services is $150.00 or $175.00 per session hour, depending on the training and experience of your psychotherapist. This includes individual, couple and family psychotherapy.
A House Calls Counseling therapist will be available 24 hours per day for urgent matters at 847.256.2000 extension 209. Please be advised, if you contact the on-call therapist outside of a scheduled session, except to reschedule an appointment, etc., you may be charged at the crisis services rate, which is $150.00 per hour charged by the quarter hour. The on-call therapist will discuss this with you at the time of the call.
1. If you or your insurance company are paying for the service:
In order to ensure the continuity of your working relationship with your therapist, it is the policy of House Calls Counseling that you provide credit card authorization, as indicated below. The Credit Card Authorization is attached. We ask that you either fill it out and return it to House Calls Counseling by mail or fax prior to your first session, or that you give it to your therapist during your first session.
a) If you have Health Insurance:
Patients who carry health insurance must remember that professional services are rendered and charged to the patient, who is responsible for their payment in full. Please remember that all health insurance policies are not the same. The amount of reimbursement depends on the type and amount of coverage your policy provides. Verification of benefits is not a guarantee of payment, and may be subject to denial upon review.
b) If you do not have Health Insurance:
- Blue Cross Blue Shield of Illinois Plan Holders:
House Calls Counseling is a Blue Cross Blue Shield (BCBS) of Illinois Preferred Provider Organization (PPO), and will submit claims for BCBS clients. House Calls Counseling will verify benefits and let you know what kind of coverage you can expect. However, verification of benefits is not a guarantee of payment; therefore, after House Calls Counseling has submitted a claim and receives payment with an Explanation of Benefits (EOB), House Calls Counseling will charge your credit card the amount indicated on the EOB as the “Patient’s Share.” If you dispute the “Patient’s Share”, you are responsible for addressing the matter with BCBS directly. Only after you have resolved the issue(s) with BCBS will House Calls Behavioral Health, P.C. re-submit claims to BCBS and adjust associated charges.
- For Clients with Other Insurance Carriers:
For all other insurance carriers, you are expected to pay the full agreed-upon rate at the beginning of each session, and you are responsible for submitting claims yourself. Your therapist will provide you with a receipt to assist you toward that end.
If you do not have health insurance, you are required to pay in full for each visit. It must be clearly understood that payment of fees for services is required at the time of service. However, if doing so may interfere with your ability to receive services, please discuss this with the therapist. Your credit card may be charged if you miss a session, if you cancel a session with less than 24-hours notice except in case of emergency, or if you have charges to your account that are over 90 days old as allowable under law and contracted agreement.
c) Keeping your account current:
We are committed to working diligently with you to keep your account current by providing you with statements and sufficient communication about your account. However, if your account becomes delinquent, we may need to suspend services while we work with you to resolve the matter. If your account remains delinquent we may need to engage the services of a collection agency, and therefore we may need to disclose limited information to pursue collection; the information we may disclose will not be used for any other purposes nor will it be re-disclosed except in connection with collection activities. Your signature, below, authorizes House Calls Behavioral Health, P.C. to release that limited information.
After discussion with the therapist you have agreed to pay $ _______ at the beginning of each session
. You may pay with cash or a personal check made out to House Calls Counseling. Otherwise, per the Credit Card Authorization form, House Calls Counseling will charge your credit card on the 15th of each month.
2. If your social service agency is paying for services:
If you or your child(ren) is/ are a client of a social service agency that is paying for services, there is no cost to you. Payment for services is handled by a contract between House Calls Counseling and your agency. House Calls Counseling will bill your agency directly.
The therapist needs to know a lot about you in order to effectively assist you to resolve the issue(s) that brought you to psychotherapy. You can rest assured that the therapist will keep all information about clients confidential. Absolutely NO information about you or your case will be released to anyone without your written authorization and consent, except as stated below:
RECORD RETENTION POLICY
- If the therapist believes that you are a danger to yourself or others, the therapist has an ethical responsibility to reduce and/or eliminate the danger, and may take action toward that end.
- If you and your family are involved with the Department of Child and Family Services (DCFS) of Illinois, House Calls Counseling is required to share information with DCFS and/or juvenile court.
- Other exceptions to confidentiality include as the Health Insurance Portability and Accountability Act (HIPAA) allows; and as indicated below regarding video consent.
- Please note that e-mail correspondence can be accessed by others across the internet, so it may not be confidential.
House Calls Counseling retains secured digital client records for at least seven years.
NOTICE OF PRIVACY PRACTICES
I hereby acknowledge that I have received and have been given an opportunity to read a copy of the Notice of Privacy Practices of House Calls Behavioral Health, P.C. I understand that if I have any questions regarding the Notice or my privacy rights, I can contact William S. Kaplan, LCSW.
I hereby authorize House Calls Behavioral Health, P.C. to videotape me, my child and/or my family as a record of the treatment sessions as indicated below by my checkmark and initials regarding the use of the videotapes.
- I agree to me, my child and/or my family’s image and/or voice appearing in videos used by my therapist to improve her/his clinical skills. I understand that the video may be reviewed by my therapist, supervisor(s), colleagues, and/or clinical consultants to provide feedback to my therapist.Yes No Initials ____
- I agree to me, my child and/or my family’s image and/or voice appearing in videos used for future psychotherapist education.Yes No Initials ____
- I agree to me, my child and/or my family’s image and/or voice appearing in videos used for research and for presentations at professional conferences.
Yes No Initials ____
In order to effectively serve you and your needs, it is important that you feel comfortable in psychotherapy at all times. If you have any questions or concerns that you feel would help to serve you better, please bring them to the attention of the therapist.
By signing this form below:
- I agree that I have been fully informed as to the purpose and procedure of videotaping and that the boxes I have checked and initialed above reflect my authorization; and
- I authorize House Calls Behavioral Health, P.C. to release limited information to a collection agency should it become necessary because my account becomes delinquent; and
- I consent to the evaluation/treatment process with House Calls Counseling; I understand that the process may include myself and/or other family members. The procedures, requirements and rules have been explained to me, and I agree to the terms therein. I understand that I have the right to withdraw from treatment at any time.