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Terms and Policy

GEORGIA NOTICE FORM
Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

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 psychologist.

– Payment is when I obtain reimbursement for your healthcare. 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 health care operations are quality assessment and improvement
activities, business-related matters such as audits and administrative services, and case
management and care coordination.

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

• “Disclosure” applies to activities outside of 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, or 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 or 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 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, 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 I have reasonable cause to believe that a child has been abused, I must
report that belief to the appropriate authority.

• Adult and Domestic Abuse – If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report that belief to the appropriate authority.

• Health Oversight Activities – If I am the subject of an inquiry by the Georgia Board of
Social Workers, Professional Counselors, and Marriage and Family Therapists, I may be required to disclose protected health information regarding you in proceedings before the Board.

• Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

• Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my
profession should determine, that you present a serious danger of violence to yourself or
another, I may disclose information in order to provide protection against such danger for you or the intended victim.

• Worker’s Compensation – I may disclose protected health information regarding you as
authorized by and to the extent necessary to comply with laws relating to worker’s
compensation or other similar programs, established by law, that provide benefits for work related injuries or illness without regard to fault.

There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.

IV. Client’s Rights and Therapist’s Duties
Client’s Rights:
• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. 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 that you are seeing me. On 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 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. 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.

Therapists Duties:
• 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 notify you with the revisions in person or by mail.

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, you may contact me at 404-685-1600

If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to me at


Courtney Geter, LMFT
1708 Peachtree Rd.
Suite 530
Atlanta, GA
30309

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VI. Effective Date, Restrictions, and Changes to Privacy Policy
This notice will go into effect on April 23, 2014
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.
( Type Full Name )
Update to Insurance and Self Pay Rate

As of September 1, 2017, Courtney Geter, LMFT, CST will no longer be an "in-network" provider with Blue Cross Blue Shield of Ga (BCBSGA). Courtney Geter, LMFT, CST attempted to renegotiate the fee schedule with her BCBSGA representative though BCBSGA declined to renegotiate in order for Courtney Geter, LMFT, CST to remain an in-network provider. The rising cost of living and overhead to maintain insurance clients are the primary reasons a higher payout from BCBS is needed.

For clients with a copay or co-insurance, Courtney Geter, LMFT will offer a discounted rate to continue services. This rate is based on your plans contracted rate and will be discussed in session. This agreed upon rate will remain until the client discharges or becomes inactive after 60 days. If you resume therapy after 60 days of discharge or inactivity, your rate may increase to the regular out of pocket rate unless Courtney Geter, LMFT, CST has space for sliding scale or discounted rates. If the contracted rate is not within your budget, Courtney Geter, LMFT is happy to provide a referral for another therapist with similar training and experience who currently accepts BCBSGA insurance.

For clients currently paying a deductible rate, Courtney Geter, LMFT will keep you at this deductible until the client discharges or becomes inactive after 60 days. If you resume therapy after 60 days of discharge or inactivity, your rate may increase to the regular out of pocket rate unless Courtney Geter, LMFT, CST has space for sliding scale or discounted rates.

For all clients, as of September 1, 2017, the regular fee for a 50-minute therapy session will increase in $130 from the current rate of $120. A 90-minute session will increase to $195 and an 110-minute session will increase to $260. Courtney Geter, LMFT, CST is implementing a grandfather clause for current and active clients. Clients who have not discharged and have attended a session at least 1x monthly (unless otherwise discussed) will remain at the current $120 rate or other agreed upon payment option. This grandfather clause will remain until the client discharges or becomes inactive after 60 days. If you resume therapy after 60 days of discharge or inactivity, your rate may increase to the new $130 rate.

If you have any questions, please feel free to bring these up during your next session.

( Type Full Name )