Patient Services Agreement

The law requires that we obtain your signature acknowledging that we have provided you with this information by the end of our first session. It is important that you understand the service agreement and the HIPAA guidelines for your privacy protection. We can discuss any questions you have. When you sign the consent form, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be effective the date the revocation is received at our office except if there are obligations imposed on us by your health insurer in order to process claims made under your policy; or if you have not satisfied your financial obligations.

While all of these requirements can seem extensive and/or complicated, they are in place for all patients with a variety of personal circumstances. These new rules are congruent with how we believe you would wish to be treated and are consistent with how Hutchinson & Associates has always operated.

Psychotherapy is not easily described in general statements. Your problems and personality will dictate the nature of your therapy. Psychotherapy is a joint venture between you and your therapist and will, of course, require your active involvement.


Your first sessions will focus on an evaluation of your concerns. By the end of the evaluation your therapist will be able to offer you some first impressions of what your therapy will include and a general plan of treatment. Therapy is usually scheduled for one 45-50 minute session per week.

You should take these same initial sessions to evaluate your experience with your new therapist. Therapy involves a large commitment of time, money, and energy, so you should select a therapist carefully. If you have questions, discuss them with your therapist whenever they arise. If you have doubts that are not answered by your therapist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.

Contacting Your Therapist

As we will not answer the phone when we are with another patient, we are often not immediately available by telephone. The telephone is answered by confidential voice mail. In emergencies, you may call our answering service toll free (1-844-820-9042), and they will contact your therapist. If he/she is unavailable, you may request that the answering service contact another member of the group.

Psychological Testing

Psychological testing may be conducted as agreed upon by you and your clinician or as requested by a third party in order to clarify specific issues. Should you decide to seek psychological testing, you will be informed in advance of the costs involved. You will be entitled to an oral account of the psychological test findings, but you will not be privy to the actual raw data of the tests. Please clarify with your psychologist what may and may not be released to third parties from this office, as certain restrictions apply to this data.

Limits on Confidentiality

The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about your treatment to others if you sign a written Authorization form that meets certain legal requirements. Your signature on the consent form provides consent for the following:

  • Consultation with other mental health professionals about our treatment for you
  • Disclosure to administrative staff for processing of your financial ledger
  • Disclosures required by health insurers (record of treatments, other protected health information)
  • Collection of overdue fees as discussed elsewhere in this Agreement
  • All these parties are bound by the same rules of confidentiality as your treating therapists.

There are some situations where we are permitted or required to disclose information without your consent or authorization. These include:

  • Child Abuse
  • Adult and Domestic Abuse
  • Health Oversight Activities
  • Judicial and Administrative Proceedings
  • Serious Threat to Health or Safety
  • Workers Compensation

If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.

The laws governing confidentiality can be quite complex, and we are not attorneys. We will attempt to answer your questions, but in situations where specific advice is required you are welcome to seek your own formal legal advice.

Professional Records

You should be aware that, pursuant to HIPAA, information about you is filed in three sets of professional records. One set is your financial ledger. If you are using insurance this ledger will also contain a medical diagnosis. Another set is your Clinical Record. It may include information about your reasons for seeking therapy, a description of the ways in which your problem impacts your life, your diagnosis, the goals we set for treatment, your progress towards those goals, your medical and social history, a record of prior treatment, reports of any professional consultations, your billing records, and any reports that have been sent to any one, including reports to your insurance carrier.

Usually you may examine and/or receive a copy of your Clinical Record if you request it in writing. This is not true if disclosure is reasonably likely to endanger you and/or others, or when another individual [other than another health care provider] is referenced and we believe disclosing that information puts the other person at risk of sustaining substantial harm. We strongly recommend that you initially review them in your therapist’s presence, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances you will be charged a copying fee of no more than 35 cents per page. The exceptions to this policy are contained in the attached HIPAA Notice Form. If we refuse your request for access to your Clinical Records, you have a right of review, which we will discuss with you upon request.

Additionally, your therapist may keep Psychotherapy Notes. These Notes are for your therapist’s own use and are designed to assist in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of therapy sessions and analysis of those sessions. They may contain sensitive information that you reveal that is not included in your Clinical Record. These Psychotherapy Notes are kept separate from your Clinical Record. Your Psychotherapy Notes cannot be sent to anyone else, including insurance companies, without your express written, signed Authorization. Insurance companies cannot require these notes as a condition of coverage nor penalize you in any way for your refusal to provide it. Psychotherapy notes are sent to third parties in rare circumstances, e.g. a lawsuit you initiate.

Patient Rights and Protection

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requests to amend your record; requests for restrictions on information recorded in your Clinical Records; requests for an accounting of disclosures of protected health information; any complaints you make about policies and procedures you wish recorded in your records; and the right to a paper copy of this Agreement and the attached HIPAA Notice form. We are happy to discuss any of these rights with you.

It is the policy of Hutchinson & Associates that no person shall be excluded from participation in, or be denied the benefits of any service or be subjected to discrimination because of race, color, nationality, religion, gender, sexual orientation, age, or disability.

You have our assurance that we will adhere to our ethical codes and professional standards and will be open to discussing any complaints you may have in this area.

If you believe your complaints are not adequately addressed you may file a formal complaint with state governmental agencies and/or a professional ethical committee.

Minors and Parents

Patients under 17 years of age who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is usually 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, we will provide them with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Before giving parents information, we will discuss the matter with the child, if possible, and receive his/her authorization. If we believe the child poses a danger to self or others, parents will be notified.

Billing and Payments

The fees for Hutchinson & Associates therapists vary slightly. Your therapist will confirm your hourly fee at your first meeting or phone call. In addition to weekly appointments, you can expect to be charged for other professional services you may need. Other services include report writing, telephone conversations lasting longer than 15 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing other services you may request. If you become involved in legal proceedings you will be expected to pay for your therapist’s professional time, including preparation and transportation costs, even if called to testify by another party. Because of the difficulty of legal involvement, you can expect to have a higher hourly rate for legal work than usual consulting fees.

Payment for service is due at the time service is rendered. We accept cash, check, MasterCard, Visa and Discover. We will accept assignment of insurance benefits, but we require your copayment at the time of service. Please note: Your health insurance is a contract between you, your employer and the insurance company. We are not a party to that contract. As a service to you we will verify by phone your benefits and bill your insurance. Please keep in mind that telephone verification is only a general description of your policy, not a guarantee of payment. We bill insurance twice a week and generally receive payment within two to four weeks. While the filing of insurance claims is a courtesy we extend to our clients, all charges are your responsibility from the date service is rendered. If your insurance company does not pay their portion of your account in 45 days, it may be transferred to your responsibility. Payment is due in 30 days.

If your account has not been paid for more than 60 days and arrangements for payment have not been made, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court. This will require the disclosure of otherwise confidential information. In most collection situations, the information released is name, social security number, date of birth, address, phone number, financial history, the nature of services provided, and the amount due. If such legal action is necessary, its costs will be included in the claim.

In situations of unusual financial hardship, your therapist may negotiate a fee adjustment or payment installment plan.

Insurance Reimbursement

In order 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 coverage for mental health treatment.  We will provide your insurance company with necessary billing information and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of your therapy fees. It is very important that you verify what mental health services your insurance policy covers. Your insurance booklet or plan administrator can provide this information. We also recommend that you contact your insurance carrier directly at their customer service center to obtain the most updated and comprehensive coverage information, as many mental health plans and coverage levels change on a frequent basis. We will be happy to help you in understanding the information you receive from your insurance company.

You should also be aware that your contract with your health insurance company may require information relevant to the services we provide to you in order to obtain reimbursement for services from your insurance carrier. We are always required to provide a clinical diagnosis. Sometimes, we are required to provide additional clinical information such as treatment plans or summaries, or an evaluation of your current mental status and/or progress. We will release the minimum information necessary for the purpose requested. Signing the consent agreement acknowledges your awareness that if your insurance is billed, this information will be provided upon their request. You always have the right to pay for our services yourself to avoid disclosure.