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Informed Consent and Disclosures (Adult)

Peak Clarity Counseling Center, 2625 Redwing Rd., Suite 110, Fort Collins, CO 80526, Ph: 970-480-0707
Dustin Johnson, LPC Professional Counselor License #11971, Georgia Tech 1998, Georgia State 2010

Informed Consent and Disclosure Statement for People 15 Years and Older

Colorado Law requires this form prior to engaging in therapy. Please read it carefully and raise any questions that you may have.

My Focus is to help clients understand the cause of their suffering and help them establish a happy, healthy, and functional life. If there does not appear to be a good match between my skills and the client’s concerns, I will make appropriate referrals. You can ask questions at any time about my counseling techniques and your counseling experience. Counseling does not necessarily cause one to feel better immediately; progress can take time and is highly related to client’s effort between sessions.

Everything discussed in our sessions is considered legally confidential with a few exceptions:

I am legally required to report suspected child abuse or elder abuse to the proper authorities.
I also may take some action without your consent if I believe you to be in danger of doing serious harm to yourself or another or if you are gravely unable to care for yourself.
If ordered by the Court I will provide reports as to your counseling.

Appointments: Most clients are on a regular appointment schedule. The quickest way to make an appointment is by email, though you may also phone.

Crisis: If you are a current client and in crisis, you may call me and I will make every effort to schedule you as soon as possible. If you are in immediate crisis contact the Suicide Prevention Helpline (800-273-8255) or go to Poudre Valley Hospital emergency room (1034 Lemay St, Ft Collins).

Fees and Payment: My self-pay rate $125.00 per 55-minute session, except for the first session, which is $150.00. I offer a $25.00 discount for cash payments. + $20.00 for each additional 10 minutes. Payment for services is due to me at the beginning of each session. I take cash, checks (made out to Peak Clarity), and credit cards. If you pay in cash, please bring the exact amount. Cancellations must be made 24 hours in advance. If you fail to do so, a $45.00 fee will be charged to you.

Insurance: If I am on your insurance panel, I will bill your insurance at your request. You will be responsible for any co-pay or deductible amounts not covered by your plan.

Records include copies of signed forms, dates of sessions, treatment plan, brief progress notes, copies of correspondence, and verification of any other contacts made. Your records are safely and confidentially stored electronically. Your records will be treated in a manner consistent with HIPPA guidelines. You have been provided a copy of the guidelines. Any request for release of this information will need your approval and signature on a written form.

Social Media and Email: I do not use social media, such as Facebook or Twitter, to stay in contact with active clients. Email is inherently not a secure form of communication. I do respond to emails, but I cannot guarantee the confidentiality of email communications.

Ending counseling will usually be agreed upon mutually. You are free to end counseling at any time. I may end your counseling, even though you wish to continue, if I believe you need services which are outside my competency, if there has been prolonged failure to make progress in our work together, or I believe you pose a threat to my safety. Should any of these occur, I will explain my decision to you and will recommend other appropriate resources.

Problems that you have with our work together can always be discussed between us. If you have a complaint that you wish to take further, you may contact the Colorado Department of Regulatory Agencies, Mental Health Section. Phone number is 303-894-7800. Address is 1560 Broadway #1350, Denver, CO. 80202. In addition, Colorado law requires that I inform you that in any professional psychotherapeutic relationship sexual intimacy is never appropriate and should be reported to the Colorado Department of Regulatory Agencies

Office Policies: Please review and indicate your understanding of each:

I understand that the recommended frequency of therapy for most issues is weekly for the first few weeks. I agree to make therapy a priority in my life, both during and between sessions.

Standard therapy sessions are 55 minutes in length. A reminder chime will sound at 50 minutes. I agree to bring up important issues early in the session so that they may be addressed adequately.

For cancellations of less than 24 hours in advance, I agree to pay a fee of $45, and that this may be charged to my credit card on file.

I understand that if I late cancel more than 2 sessions in any 3-month period, future appointments may be cancelled and I may have to wait until there are new openings in the practice before rescheduling.

I accept that email is inherently insecure. If I choose to correspond with my therapist by email, I accept the risks that come with it.

You have been provided with a copy of this document. Signing below indicates you have been informed of Dustin Johnson’s degrees and licensing status. Additionally, you have read the preceding information and understand you rights as a client. You have been provided information about crisis resources.

Please sign with your full legal name.

I have read and understand all of the Informed Consent and Disclosure items above.

Surprise/Balance Billing Disclosure Form – Know Your Rights

Beginning January 1, 2020, Colorado state law protects you* from “surprise billing,” also known as “balance billing.” These protections apply when:

- You receive covered emergency services, other than ambulance services, from an out-of-network provider in Colorado, and/or
- You unintentionally receive covered services from an out-of-network provider at an in-network facility in Colorado

What is surprise/balance billing, and when does it happen?
If you are seen by a health care provider or use services in a facility or agency that is not in your health insurance plan’s provider network, sometimes referred to as “out-of-network,” you may receive a bill for additional costs associated with that care. Out-of-network health care providers often bill you for the difference between what your insurer decides is the eligible charge and what the out-of-network provider bills as the total charge. This is called “surprise” or “balance” billing.

When you CANNOT be balance-billed:
Emergency Services
If you are receiving emergency services, the most you can be billed for is your plan’s in-network cost-sharing amounts, which are copayments, deductibles, and/or coinsurance. You cannot be balance-billed for any other amount. This includes both the emergency facility where you receive emergency services and any providers that see you for emergency care.

Nonemergency Services at an In-Network or Out-of-Network Health Care Provider
The health care provider must tell you if you are at an out-of-network location or at an in-network location that is using out-of-network providers. They must also tell you what types of services that you will be using may be provided by any out-of-network provider.

You have the right to request that in-network providers perform all covered medical services. However, you may have to receive medical services from an out-of-network provider if an in-network provider is not available. In this case, the most you can be billed for covered services is your in-network cost-sharing amount, which are copayments, deductibles, and/or coinsurance. These providers cannot balance bill you for additional costs.

Additional Protections
- Your insurer will pay out-of-network providers and facilities directly.
- Your insurer must count any amount you pay for emergency services or certain out-of-network services (described above) toward your in-network deductible and out-of-pocket limit.
- Your provider, facility, hospital, or agency must refund any amount you overpay within sixty days of being notified.
- No one, including a provider, hospital, or insurer can ask you to limit or give up these rights.

If you receive services from an out-of-network provider or facility or agency OTHER situation, you may still be balance billed, or you may be responsible for the entire bill. If you intentionally receive nonemergency services from an out-of-network provider or facility, you may also be balance billed.

- If you want to file a complaint against your health care provider, you can submit an online complaint by visiting this website: https://www.colorado.gov/pacific/dora/DPO_File_Complaint.

- If you think you have received a bill for amounts other than your copayments, deductible, and/or coinsurance, please contact the billing department, or the Colorado Division of Insurance at 303-894-7490 or 1-800-930-3745.

*This law does NOT apply to ALL Colorado health plans. It only applies if you have a “CO-DOI” on your health insurance ID card.
- Please contact your health insurance plan at the number on your health insurance ID card or the Colorado Division of Insurance with questions.

I have read and understand all of the Surprise/Balance Billing Disclosure Form above.

HIPAA Notice of Privacy Practices

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.

Your Rights

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

Your Choices

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

Your Rights

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 using the information on page 1.
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 hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.

Your Choices

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

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.

Treat you

We can use your health information and share it with other professionals who are treating you.

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: We use health information about you to manage your treatment and services.

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

Do research

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.

I have read and understand the HIPAA Notice of Privacy Practices above.

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February 20, 2022 7:15 pm MST

Informed Consent and Disclosures (Adult) Uploaded by Dustin Johnson - Dustin@PeakClarity.com IP 73.14.180.172