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PSYCHOLOGICAL SERVICES
Psychotherapy is not easily described
in general statements. It varies depending on the personality of both the therapist and the patient and the particular problems
that the patient brings. There are a number of different approaches that can be utilized to treat the problems you hope to
address. It is not like visiting a medical doctor, in that it requires a very active effort on your part. In order to be successful,
you will have to work both during our sessions and at home.
Psychotherapy has both benefits and risks. Risks sometime
include experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, anger and frustration, loneliness and
helplessness. Psychotherapy often requires recalling unpleasant aspects of your history. Psychotherapy has also been shown
to have benefits for people who undertake it. It often leads to a significant reduction of feelings of distress, and better
relationships and resolutions of specific problems, but there are no guarantees about what will happen.
You can expect
that I will share how I understand the problems you’ve brought to my attention, how I would go about treating them, what other
approaches I am aware of, the advantages/disadvantages of each, and, to the best of my knowledge, what might happen without
treatment.
SESSION LENGTH
Sessions are scheduled for 50 minutes.
PROFESSIONAL FEES
You will be expected
to pay for each session at the time it is held or, if you prefer, you may pay in advance for any number of sessions. You will
also be expected to pay for any session that is not canceled at least 48 hours in advance.
FREQUENT CANCELLATIONS
There
are times during the course of treatment that for urgent, personal or professional reasons one must cancel a therapy appointment.
Since you are reserving an hour per week in my schedule, there is a limit to the number of on time (48 hour) “no-charge” cancellations.
The maximum number of on-time cancellations without a charge is five times. Thereafter, you will be expected to pay for the
hour you are reserving for treatment unless you have made other arrangements with me sufficiently in advance.
INSURANCE
REIMBURSEMENT
I do not accept insurance reimbursement as a form of payment. If you have a health insurance policy that
provides coverage for some or all of your mental health treatment, you will be expected to pay for your services with me up
front and then request reimbursement directly from your insurance company. I am happy to assist you in completing any necessary
forms in this regard. Be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis
and, in rare cases, a copy of your entire mental health record. 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. It is important to remember that you always have
the right to pay for my services yourself (and not request reimbursement from your health insurance company) and thereby avoid
the complexities that are described above.
CONTACTING ME
My telephone is answered by a voice mail system, which
I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of weekends
and holidays. If you are difficult to reach, please leave some times when you will be available. If I am unavailable for an
extended time due to vacation, illness, or any other reason, I will provide you with the name of a trusted colleague whom
you can contact if necessary.
BREAKS IN TREATMENT
Occasionally, I may be unavailable to meet with you for a brief
period of time due to vacations, illness, or professional leave. When I take time away from my practice, I will provide you
with substantial advance notice of the break in treatment and I will always provide you with the name and number of a colleague
who will be providing coverage for me during my absence.
PROFESSIONAL RECORDS
Both law and the standards of
my profession require that I keep appropriate treatment records. You are entitled to receive a copy of the records, unless
I believe that seeing them would be emotionally damaging, in which case, I will be happy to provide them to an appropriate
mental health professional of your choice. Because these are professional records, they can be misinterpreted and/or can be
upsetting, so I recommend that we review them together so that we can discuss what they contain.
CONFIDENTIALITY
In
general, the confidentiality of communications between a patient and a psychologist is protected by law, and I can only release
information about our work to others with your written permission. However, there are a number of exceptions.
In most
judicial proceedings, you have the right to prevent me from providing any information about your treatment. However, in some
circumstances such as child custody proceedings and proceedings in which your emotional condition is an important element,
a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it. There are some
situations in which 1) I am legally required to take action to protect others from harm, even though that requires revealing
some information about a patient’s treatment. 2) If I believe that a child, an elderly person, or a disabled person is being
abused, I must file a report with the appropriate state agency. 3) If I believe that a patient is threatening serious bodily
harm to another, I am required to take protective actions, which may include notifying the potential victim, notifying the
police, or seeking appropriate hospitalization. 4) If a patient threatens to harm him/herself, I may be required to seek hospitalization
for the patient, or to contact family members or others who can help provide protection.
These situations have rarely
arisen in my practice. Should such a situation occur, I will make appropriate efforts to fully discuss it with you before
taking any action.
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Notice of Privacy Practices by Dr. Samuel
Jinich
I am committed to protecting medical/mental health information about you. As part of my standard practices,
I create a record of the care and services you receive by me for use in your care and treatment.
• I am required by
law to make sure your mental health information is protected. Please review the following important information:
An
Introduction to Privacy Rights for Psychology Clients
You may have heard about the complex new federal privacy rule under
the Health
Insurance Portability and Accountability Act, better known as HIPAA. It is important
that, as my client,
you understand what this rule means, and how it could affect you.
In general, HIPAA establishes requirements for how I
-- as well as other health care
professionals and organizations -- use and disclose your records. HIPAA also provides
certain
basic privacy rights and helps clarify all patient privacy rights, including those
that exist under state law.
Following
is a brief summary of the HIPAA rule. I will also be providing you with a
detailed notice of your privacy rights, which
is a requirement of HIPAA.
Under the HIPAA rules:
• I will exercise even greater care in handling your records to prevent
unauthorized
individuals from seeing them.
• You generally have the right to review your records, receive a copy of
them, and
request that any errors be corrected. In certain situations, I have the right to deny
such requests.
•
You have increased protection from insurance companies and others who may ask
to see your records.
• You are able to
request certain restrictions on the disclosure of your records –
although I may use my best judgment about whether to comply
with your request.
• You have the right to receive confidential communications of health information
at any location
you specify. For example, a client may request that a bill be sent to
an address other than his or her home, or ask me
not to leave any messages on a
home answering machine.
Be assured that I consider maintaining my clients’ privacy a
critical component of my
practice. Please don’t hesitate to let me know if you have any questions about the new
HIPAA
privacy rule.
HIPAA Disclosure . . . . . . . . . . . . . . . . . . . .
Notice of Psychologists’ 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, 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 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 I have reasonable cause
to believe that a child has suffered abuse or neglect, I am required by law to report it to the proper law enforcement agency
or the Washington Department of Social and Health Services.
Adult and Domestic Abuse: If I have reasonable
cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, I must immediately
report the abuse to the California Department of Social and Health Services. If I have reason to suspect that sexual or physical
assault has occurred, I must immediately report to the appropriate law enforcement agency and to the Department of Social
and Health Services.
Health Oversight: If the California Board of Psychology subpoenas me as part of
its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed
psychologists, I must comply with its orders. This could include disclosing your relevant mental health information.
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 to you and the records thereof, such information is privileged under state
law, and I will not release information without the written authorization of you or your legal representative, or a subpoena
of which you have been properly notified and you have failed to inform me that you are opposing the subpoena, 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: I may disclose your
confidential mental health information to any person without authorization if I reasonably believe that disclosure will avoid
or minimize imminent danger to your health or safety, or the health or safety of any other individual.
Worker’s Compensation: If you file a worker's compensation claim, with certain exceptions, I must make available, at any stage
of the proceedings, all mental health information in my possession relevant to that particular injury in the opinion of the
California Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries
upon request.
IV. Patient's Rights and Psychologist's Duties
Patient’s Rights:
• Right to Request Restrictions
–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 that 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 III 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.
Psychologist’s 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 date and post a copy of the revisions to http://www.samueljinich.com.
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, Samuel Jinich, Ph.D. at (415) 474-6414.
If you believe
that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written notice
of your complaint to me, Samuel Jinich, Ph.D.; 1902 Webster Street; San Francisco, CA 94115.
You may also send a written
complaint to the Secretary of the U.S. Department of Health and Human Services. I will be happy to 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 August 1, 2005.
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. Revisions to this notice will be posted to this website at the time of revision. I
will be happy to provide you with a written copy of these revisions upon request.
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