Use and Disclosure of Your Health Information

For Treatment - Your PHI may be used and disclosed by those involved in your care for the purpose of providing, coordinating, or managing your health care treatment and related services. This includes consultation with clinical supervisors or other treatment team members. 

For Payment - PHI may be used or disclosed to receive payment for the services provided to you. Examples include making a determination of eligibility or coverage of insurance benefits, processing insurance claims, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, only necessary PHI for payment will be disclosed. 

For Health Care Operations - Your PHI may be used or disclosed to support business activities including, but not limited to, quality assessment activities, employee review activities, reminding you of appointments, to provide information about treatment alternatives or other health related benefits and services, licensing, and conducting or arranging for other business activities. For example, PHI may be shared with third parties that perform business services related to your treatment. 

For Legal Compliance - Under the law, disclosures to you about your PHI may be provided at your request. In addition, disclosures may be made to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining compliance with the requirements of the Privacy Rule.

Without Authorization -- The following categories allow for disclosure of PHI without an authorization: abuse and neglect, emergencies, judicial and administrative proceedings, law enforcement, national security, public safety (duty to warn). 

Verbal Permission - With your verbal permission, disclosure of PHI may be made to family members that are directly involved with your care.

With Authorization - Use and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked.

Your Rights

You have the following rights regarding your personal PHI maintained by this office. To exercise any of these rights, please submit a written request to your therapist:

To Inspect and Copy - You have the right, which may be restricted in specific circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to access your PHI will be restricted only in those situations where there is compelling evidence that access would cause harm to you. I may charge a reasonable, cost-based fee for copies.

Right to Amend - If you feel that the PHI on record about you is incorrect or incomplete, you may request to correct or amend, although I am not required to agree to such amendment.

Right to Accounting of Disclosures - You have the right to request an accounting of certain disclosures of your PHI. Right to Request Restrictions - You have the right to request a restriction or limitation of the use or disclosure of your PHI for treatment, payment, or health care operations, although I am not required to agree to your request.

Right to a Copy of This Notice - You have the right to a copy of this Notice.

Acknowledgment of Receipt of Notice of Privacy Practices for Protected Health Information (PHI)

I have had the opportunity to review the Notice of Privacy Practices of Rhonda Myers, LPC. I understand that the terms of this Notice may change from time to time, in which case I will be notified of such changes, either verbally or in writing. 

I understand that I have the right to request to restrict the use and disclosure of PHI for carrying out treatment, payment, and/or health care operations. I understand that Rhonda Myers, LPC is not required to agree to any restriction, and that treatment may be conditional upon signing of this Consent.

I understand that I have the right to revoke this Consent, in writing, at any time, except to the extent that Rhonda Myers, LPC has acted in reliance hereon.

By my signature below, I give my consent for Rhonda Myers, LPC to use and disclose, for the purpose of carrying out treatment, payment, and/or health care operations, protected health information (PHI) in reference to:

Welcome and thank you for choosing Rhonda Myers Counseling for your counseling concerns. This document provides you with information about the nature of our work together, office policies, and your rights. Please read carefully and inquire if you have any questions or need further clarification:

Informed Consent: Counseling has both benefits and risks. It can enhance emotional well-being, promote personal growth, reduce worry and distress, improve the quality of relationships, and resolve issues of concern. However, when you are addressing difficult situations and relationship problems, you may experience increased stress and uncomfortable emotions such as sadness, guilt, anger, frustration, etc.  You may decide to make changes in your life that affect your relationships in unexpected ways. 

Counseling is a collaborative process and is most effective when client and therapist have a good working relationship. The initial appointment is a consultation to determine counseling fit and recommendations for next steps. Should we agree to work together, counseling goals and a plan for treatment will be established. I utilize a variety of approaches based on the presenting concerns, your preferences and feedback, and my assessment of treatment needs. These include, but are not limited to, Cognitive-Behavioral (CBT), Dialectical (DBT), Psychodynamic, Developmental, Existential, Systems, and Emotionally Focused Therapy (EFT). If you are dissatisfied with how our work is progressing, please address this with me. 

Confidentiality: Our work together and your status as a client is confidential and will not be disclosed to anyone without your permission. However, there are situations where legal obligations require the release of protected information, as follows: 1) there is reason to believe there is immediate danger to yourself or others, 2) situations involving abuse of children, elderly adults, or disabled individuals, or 3) a court order for client records. To provide high quality care, I may consult from time to time with other professionals. Confidentiality regarding client identity and personally identifiable information will be protected. If you wish to include others in your treatment planning, and for coordination of care, you may sign a separate Consent for Release of Information Form.

Telephone Calls and Emergency Procedures: As a private practice clinician I am in session most of the day and unable to provide on-call or emergency services. In a case of crisis or emergency, contact Crisis Intervention at 717-394-2631 (for Lancaster County), the National Suicide and Crisis Lifeline at 988, or go to your local Emergency Room. I make every attempt to return calls and messages within 24 hours during normal business hours. Please limit phone calls to scheduling changes or matters than can not wait until your next appointment.

Appointments and Cancellations: Your appointment time is reserved for you. You may cancel or reschedule appointments by phone or email with a minimum of 24-hour advance notice. Monday cancellations should be made by the previous Friday if possible. Missed appointments and cancellations made with less than 24-hour notice will be charged the regular session fee.

Fees: for Rhonda Myers, MS, LPC:  Individual Counseling (60 minutes) $160, Initial Couples Consultation Appointment (90 minutes) $300, Couples Therapy (90 minutes) $240, Fees for Intensives are determined based on structure and length of the Intensive and provided via a separate agreement.

Fees for Amy Labagh, MS, NCC:    Individual Counseling (60 min) $110

You agree to provide credit card information, which will be securely stored, for the purpose of Telehealth (video or phone) appointments, late cancellations, or missed appointments. Cash, check, major credit cards, Health Savings accounts (HSA), and Flexible Spending Accounts (FSA) are accepted.

Insurance: I do not contract with insurance companies. However, if you have an out-of-network benefit, I can provide you with a form that you may submit for possible reimbursement from your insurance company. Please be aware that submission of claims to insurance requires a diagnosis. If you have a Health Savings Account (HSA) or a Flexible Spending Account (FSA), you may be able to use those plans to cover fees. Please check with your plan administrator to determine eligibility.

Privacy Practices, Records, and Your Rights: You have received, as part of the Intake Paperwork, a separate document that describes your rights and my responsibilities regarding privacy, your records, and use of your information. This information is part of HIPAA (Health Insurance Portability and Accountability Act) and is also posted at my office.

Confidentiality of email, text, and video communication: I use a secure electronic health records system through which you may transmit confidential messages and documents. Video appointments are conducted using a secure Telehealth platform. Texts and emails are not secure mediums for communication and your personal information could be accessed by others. Therefore, please limit texts and emails to scheduling or other general inquiries. Should you choose to email or text, you do so with the understanding and acceptance of the risks. 

Termination: You may decide to end treatment at your discretion. It is good practice to discuss termination and identify a plan to maintain your progress. When you feel ready to end our work together, please let me know. There could be times when I initiate termination -- when a higher level of care is warranted, if I feel unable to help you, or if the presenting concern is outside of my expertise. I will assist you with referrals if that is the case. Once we have concluded our work you will no longer be considered a client, and should you wish to resume services with me, it would be considered a new episode of therapy.

Your signature below indicates that you have read and understand the policies described and agree to the terms of this counseling agreement. Please keep a copy of the document for your reference.

Credit Card Authorization

By your electronic signature of this form, you authorize charges to your credit card through CardConnect for services rendered. These charges will appear on your bank/credit card statement as Rhonda Myers, LPC. You have the right to request a paper copy of this document. 

I authorize Rhonda Myers, LPC to charge my credit card through CardConnect. I also agree that my credit card can be charged for any session that is not cancelled at least 24 hours prior to the scheduled session. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify my therapist in writing of any changes in my account information or termination of this authorization.

I certify that I am an authorized user of this credit card and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms indicated in this authorization form. I acknowledge that credit card transactions could be linked to Protected Health Information.

I understand that there may be times when I wish to utilize teletherapy as part of my counseling. I understand that can include the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications.  

The laws that protect the confidentiality of my medical information also apply to teletherapy. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including but not limited to: reporting child, elder, and dependent adult abuse; reason to belief that I or someone else is in danger of harm; a court order by a judge. 

I understand that teletherapy does not provide emergency services, and if I am a danger of harm to myself or others, that I will seek help by calling 911, going to my local hospital emergency room, or calling the National Suicide Hotline at 1-800-273-8255.

I understand that there are both benefits and risks from teletherapy. Benefits can include the ease and convenience of access to appointments without having to travel to a physical office location. Risks include, but are not limited to, the possibility that despite reasonable efforts on the part of my therapist, that the transmission of medical information could be disrupted or distorted by technical failures or by unauthorized persons, and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, there may be technical or service disruptions that interfere with video communication during a scheduled appointment.

I understand and agree to notify my therapist in advance to schedule counseling sessions and to give 24-hour notice of cancellations. Failure to give adequate cancellation notice (24 hours) will result in a missed appointment charge.  I give permission to charge my credit card, which will be held on file, for telehealth counseling sessions and missed appointment fees. My signature below indicates that I have read and understand the information as described and agree to discuss with my therapist any questions or concerns about these policies.