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Terms and Policy

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information.

I. Uses and Disclosures for Treatment, Payment and Health Care Operations
I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

"PHI" refers to information in your health record that could identify you.

"Treatment, Payment and Health Care Operations"
Treatment is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another mental health provider.

Payment is when I obtain reimbursement for your health care. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and case coordination.

"Use" applies only to activities within my office, such as sharing, applying, utilizing, examining and analyzing information that identifies you.

"Disclosure" applies to activities outside my office, such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization
I may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, and health care operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your psychotherapy notes. "Psychotherapy notes" are notes that I have made about our conversation during a private, group, joint, or family counseling session,
which I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI.

You may revoke all such authorizations (of PHI or psychotherapy notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:

Child Abuse: If, in my professional capacity, a child comes before me which I have reasonable cause to suspect is an abused or maltreated child, or I have reasonable cause to suspect a child is abused or maltreated where the parent, guardian, custodian or other person legally responsible for such child comes before me in my professional or official capacity and states from personal knowledge facts, conditions or circumstances which, if correct, would render the child an abused or maltreated child, I must report such abuse or maltreatment to statewide central register of child abuse and maltreatment, or the local child protective services agency.

Health Oversight: If there is an inquiry or complaint about my professional conduct to the Pennsylvania State Board of Social Workers, Marriage and Family Therapists and Professional Counselors, I must furnish to the Pennsylvania Commissioner of Professional and Occupational Affairs, your confidential mental health records relevant to this inquiry.

Judicial or Administrative Proceedings: 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 privileged under state law, and I must not release this information without your written authorization, or a court order. This privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. I must inform you in advance if this is the case.

Serious Threat to Health or Safety: I may disclose your confidential information to protect you or others from a serious threat of harm by you.

Worker's Compensation: If you file a worker's compensation claim, and I am treating you for the issues involved with that complaint, then I must furnish to the chairman of the Worker's Compensation Board records which contain information regarding your psychological condition and treatment.

IV. Patient's Rights and Licensed Clinical Social Worker's Duties
Patient's Rights:
Right to Request Restriction - You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know you are seeing me. Upon your request, I will send your bills to another address.)

Right to Inspect and Copy - You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.

Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.

Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section II of this Notice). On your request, I will discuss with you the details of the accounting process.

Right to a Paper Copy - You have the right to obtain a paper copy of the notice from me upon request, even if you have agreed to receive the notice electronically.

Licensed Clinical Social Worker's Rights:
I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.

I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.

If I revise my policies and procedures, I will provide you with a revision notice.

V. Questions and Complaints
If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, please let me know. You may contact me at the following:

Marquita Bolden, LCSW
6060 Ridge Avenue, Suite 210
Philadelphia, PA 19128

If you believe that your privacy rights have been violated you may file a complaint with me. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. You may write to:

Office for Civil rights
US Department of Health and Human Services
150 S. Independence Mall West
Suite 372, Public Ledger Building
Philadelphia, PA 19106-9111

You have specific rights under the Privacy Rule. I will not retaliate against you for
exercising your right to file a complaint.

VI. Restrictions and Changes to Privacy Policy
I reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that I maintain. I will provide you with a revised notice by notifying you.
( Type Full Name )
Welcome and thank you for choosing me to work with you! Below is an agreement between us regarding our working relationship. We can discuss any questions concerning this agreement at any time.

As a client in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. I, as your therapist, have corresponding responsibilities to you.

Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits. Psychotherapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. But, there are no guarantees about what will happen. Psychotherapy requires a very active effort on your part. In order to be most successful, you will have to work on psychotherapy goals outside of sessions.

Our first few sessions will involve an evaluation of your situation and needs; and we will discuss goals that you want to work toward during psychotherapy. During evaluation time, we can both decide if I am the best person to provide the services that you need. Since psychotherapy can involve a significant investment of time, energy and money, it is important that you select a therapist with whom you are comfortable working. If you have questions about some aspect of our work together, please discuss them with me. If you decide that you do not want to continue in psychotherapy with me, please tell me. If you want me to help you find another therapist or other appropriate resources, I will do so.

If you have been referred to me for psychotherapy and related services by Karen Smith or Full Living, then your fee agreement, along with any other related fees for professional services, is determined by and payable to Ms. Smith of Full Living at 1632 Chattin Road, Laverock, PA 19038. Please contact Ms. Smith at 215-4940-7818 or at with any questions or concerns regarding fees for services or payment issues.

Appointments will ordinarily be 45-50 minutes in duration, once per week at a time we agree on, although some sessions may be more or less frequent as needed. If you need to cancel or reschedule a session, I ask that you provide me with 24 hours notice. If you miss a session without canceling, or cancel with less than 24 hour notice, my policy is to collect a fee of $40 (unless we both agree that you were unable to attend due to circumstances beyond your control). In addition, you are responsible for coming to your session on time; if you are late, your appointment will still need to end on time.

The standard fee for each session is $120. You are responsible for paying at the time of your session unless prior arrangements have been made. Payment must be made by check, cash, or credit card. If you are unable to afford the standard fee of $120, a reduced fee may be discussed.

Any checks returned to my office are subject to an additional fee of $35.00 to cover the bank fee that I incur. Any returned check may result in you being asked to pay in cash for future sessions. If you refuse to pay your debt, I reserve the right to use an attorney or collection agency to secure payment.

It is my practice to charge a fee of $40 per hour for other professional services that you may require such as report writing, telephone conversations that last longer than 15 minutes, attendance at meetings or consultations which you have requested, or the time required to perform any other service which you may request of me. If you anticipate becoming involved in a court case, I recommend that we discuss this fully before you waive your right to confidentiality. If your case requires my participation, you will be expected to pay for the professional time required even if another party compels me to testify.

In order for us to set realistic goals and priorities, it is important to evaluate what resources are available to pay for your therapy. If you have a health benefits policy, it will usually provide some coverage for mental health treatment. I am not enrolled on any insurance panels at this office location and thus your treatment will likely be considered "out of network." I will provide you with a receipt that includes the information insurance companies need to process your claim for reimbursement and you can opt to file your own claims. Remember that you, not your insurance company, are responsible for full payment of my fees.

Please read carefully the section in your insurance coverage booklet, which describes mental health services. If you have questions, you should call your plan and ask the insurance representative. I will, of course, provide whatever help I can in deciphering the information you get from your carrier about your coverage.

The rising cost of health care has resulted in an increasing level of complexity about insurance benefits that sometimes makes it difficult to determine exactly how much mental health coverage is available. "Managed Health Care Plans" such as HMOs and PPOs often require advance authorization before they will provide reimbursement for mental health services. If you are planning to use your insurance to help pay for therapy with me, you will want to ask your insurance representative if they cover my services. Many plans are oriented towards a short-term treatment approach designed to resolve specific problems that might be interfering with one's usual level of functioning. It may be necessary to seek additional approval after a certain number of sessions. In my experience, while quite a lot can be accomplished in short-term therapy, many clients feel that more services are necessary after insurance benefits expire.

You should also be aware that most insurance agreements require you to authorize me to provide a diagnosis of mental illness. This diagnosis will become part of your permanent medical record. Sometimes additional clinical information such as a treatment plan or summary, or, in rare cases, a copy of the entire record is also required. This information will become part of the insurance company files, and, in all probability, some of it will be computerized. All insurance companies claim to keep such information confidential, but once it is in
their hands, I have no control over what they do with it. In some cases they may share information with a national medical information data bank. If you request it, I will provide you with a copy of any report that I submit to your insurance carrier. Please remember that you always have a choice to bypass the insurance altogether and pay a negotiated fee out of pocket. By signing this agreement you are giving me permission to release information requested by your carrier.

The laws and standards of my profession require that I keep treatment records. You are entitled to examine and/or receive a copy of your records if you request it in writing unless I believe that seeing them would be emotionally damaging, in which case I will send them to a mental health professional of your choice. Because these are professional records, they may be misinterpreted and/or upsetting to untrained readers. For this reason, I recommend that you initially review them with me, or have them forwarded to another mental health professional to discuss the contents. If I refuse your request for access to your records, you have a right to have my decision reviewed by another mental health professional, which I will discuss with you upon your request. You also have the right to request that a copy of your file be made available to any other health care provider at your written request. I may charge you for the costs of preparing, copying and sending your records if you request them.

My policies about confidentiality, as well as other information about your privacy rights, are fully described in a separate document entitled Notice of Privacy Practices. You have been provided with a copy of that document and we have discussed those issues. Please remember that you may reopen the conversation at any time during our work together.

Contents of all psychotherapy sessions are considered to be confidential. Both verbal information and written records about you cannot be shared with another party without your written consent or the written consent of your legal guardian. Exceptions to the rules of confidentiality are as follows:

1. If there is good reason for me to believe you are threatening serious bodily harm to yourself or others, I may be required to take protective actions, which may include notifying the potential victim, notifying the police, seeking appropriate hospitalization, or to contact family members or others who can provide protection.

2. If you state or suggest that you are abusing a child or vulnerable adult, or have recently abused a child or vulnerable adult, or a child or vulnerable adult is in danger of abuse, I am required to report this information to the appropriate social service and/or legal authorities.

3. In response to a court order or where otherwise required by law.

4. To the extent necessary, to make a claim on a delinquent account via a collection agency.

5. To the extent necessary for emergency medical care to be rendered.

I may find it necessary to consult with other professionals about your treatment so that I can provide you with the best possible service. During a professional consultation, I will not provide any identifying information about you. The professional consultant will also be legally bound to keep all information confidential.

While privacy in psychotherapy is crucial to successful progress, parental involvement can also be essential. For children under 14 years, please be aware that the law may provide the child's legal guardian the right to examine the child's treatment records. For children 14 and older, I request an agreement between the client and the legal guardian or caregiver allowing me to share general information about treatment progress and attendance. All other communication will require the child's agreement, unless I feel there is a safety concern (see also above section on Confidentiality for exceptions), in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle any objections that are raised.

Should you need to reach me outside of our scheduled sessions, you can do so by phone at 267-227-0122 or by email at Marquita@marquitabolden. com. However, despite my use of security measures, I cannot guarantee confidentiality of communication by phone or Internet. It is very important to be aware that computers and unencrypted email, texts, and e-fax communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Emails, texts, and e-faxes, in particular, are vulnerable to such unauthorized access due to the fact that servers or communication companies may have unlimited and direct access to all emails, texts and e-faxes that go through them. It is always a possibility that e-faxes, texts, and email can be sent erroneously to the wrong address and computers. Also, be aware that my phone messages are transcribed and sent to my computer via unencrypted emails. Please notify me if you decide to avoid or limit, in any way, the use of email, texts, cell phones calls, phone messages, or e-faxes. If you communicate confidential or private information via unencrypted email, texts or e-fax or via phone messages, I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and I will honor your desire to communicate on such matters.

I am often not immediately available by telephone. I do not answer my phone when I am with clients or otherwise unavailable. At these times, you may leave a message on my voice mail. I will make every effort to return your call within 24 hours, with the exception of weekends and holidays.

If for any number of unseen reasons, you do not hear from me or I am unable to reach you and you feel you cannot wait for a return call or if you feel unable to keep yourself safe, then you should immediately consult one of the following: 1) Montgomery County Emergency Service Inc, located at 50 Beech Drive in Norristown, PA 19403 (610-279-6100 or toll free at 1-800-452-4189); 2) the nearest hospital emergency room; or 3) 911 and ask to speak to the mental health worker on call.

If you are unhappy with what is happening in psychotherapy, I hope you will will talk with me so that I can respond to your concerns. Such comments will be taken seriously and handled with care and respect. You may also request that I refer you to another therapist and are free to end psychotherapy at any time. You have the right to considerate, safe and respectful care, without discrimination as to race, ethnicity, color, gender, sexual orientation, age, religion, national origin, or source of payment. You have the right to ask questions about any aspects of psychotherapy and about my specific training and experience. You have the right to expect that I will not have social or sexual relationships with clients or with former clients.

While I share office space with other professionals, our professional practices are independent.

Your signature below indicates that you have read this Agreement and the Notice of Privacy Practices and agree to their terms. Your signature below also indicates that you consent to participate in evaluation and/or psychotherapy. Your signature below also indicates that you are in agreement with the contents of this document.
( Type Full Name )