Payment information will be collected at the time of the appointment

    Notice of Privacy Practices

    This notice describes how mental health information about you may be used and disclosed and how you may obtain access to this information. Please review this notice carefully.

    Understanding Your Protected Health Information (PHI)

    When you visit us, a record is made of your symptoms, assessments, diagnoses, treatment plan, and other mental health or medical information. In using and disclosing your protected health information (PHI), it is our objective to follow the Privacy Standards of the Federal Health Insurance Portability and Accountability Act (HIPAA) and requirements of Texas law.

    Your mental health and/or medical record serves as

    • – a basis for planning your care and treatment
    • – a means of communication among the health professionals who may contribute to your care
    • – a legal document describing the care you received
    • – a means by which you or a third-party payer can verify that services billed were actually provided
    • – a tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

    Responsibilities of Meadows Counseling Center

    We are required to:

    • - Maintain the privacy of your protected health information (PHI) as required by law and provide you with notice of our legal duties and privacy practices with respect to the protected health information that we collect and maintain about you.
    • - Abide by the terms of this notice currently in effect. We have the right to change our notice of privacy practices and to make the new provisions effective for all protected health information that we maintain, including that obtained prior to the change. Should our information practices change, we will post new changes in the reception room and provide you with a copy, upon request.
    • - Notify you if we are unable to agree to a requested restriction.
    • - Use or disclose your health information only with your authorization except as described in this notice.

    Your Protected Health Information (PHI) Rights

    You have the right to:

    • - review and obtain a paper copy of the notice of privacy practices upon request and of your health information. Copy charges may apply.
    • - request and provide written authorization and permission to release information for purposes of outside treatment and health care operations.
    • - request a restriction on certain uses and disclosures of protected health information, but we are not required to agree to the restriction request.
    • - Meadows Counseling Center is not required to agree to the requested amendment and amendments do not apply to records subpoena by the courts.

    Professional Records

    The laws and standards of our profession require that we keep Protected Health Information about you in your Clinical Record. Your Clinical Record includes information about your reasons for seeking therapy, a description of the ways in which your problem affects your life, your diagnosis, the goals for treatment, your progress toward those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, any payment records, and copies of any reports that have been sent to anyone. You may examine and/or receive a copy of your Clinical Record. Meadow Counseling Center, LLC does not release records without proper documentation. All requests made by patients, parents or guardians must be made in writing and proper documentation given. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. Therefore, it is recommended that you initially review them in the presence of the therapist, or have them forwarded to another mental health professional so you can discuss the contents. In most circumstances, Meadows Counseling Center is allowed to charge a copying fee of $25.00.

    There are some situations in which the therapist is legally obligated to reveal some information about a client’s treatment. If such a situation arises, we will make every effort to fully discuss it with you before taking any action and will limit disclosure to what is absolutely necessary.

    Duty to Warn and Protect

    When a client discloses intentions or a plan to harm another person, the mental health professional is required to warn the legal authorities. In cases in which the client discloses or implies a plan for suicide, the health care professional is required to notify legal authorities and make reasonable attempts to notify the family of the client.

    Abuse of Children and Vulnerable Adults

    If a client states or suggests that a child in his or her care is being abused (or vulnerable adult) or has recently been abused (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.

    Prenatal Exposure to Controlled Substances

    Mental Health care professionals are required to report admitted prenatal exposure to controlled substances that are potentially harmful.

    Insurance Providers (when applicable)

    Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes type of services, dates/times of services, diagnosis, treatment plan, and description of impairment, progress of therapy, case notes and summaries.

    “I agree to the above limits of confidentiality and understand their meanings and ramifications.”

    Client Financial Responsibility Statement

    You are responsible for coming to your session on time and at the time we have scheduled. Sessions last for 45-50 minutes. If you are late, we will end on time and not run over into the next person’s session. If you fail to cancel a scheduled appointment, we cannot use this time for another client and you will be billed for your missed appointment. A $50 fee is charged for missed appointments or no show cancellations with less than a 24 hour notice unless due to illness or an emergency.

    A bill will be mailed directly to all clients who do not show up for or cancel an appointment without 24 hour notice. The voicemail has a time and date stamp which will keep track of the time that you called to cancel. We cannot bill these sessions to your insurance.

    You are responsible for paying for your session weekly unless we have made other firm arrangements in advance. Our fee for a session is $120.00 and $140.00 for initial evaluation. If we decide to meet for a longer session, I will bill you prorated on the hourly fee. Emergency phone calls of less than ten minutes are normally free. However, if we spend more than 10 minutes in a week on the phone, if you leave more than ten minutes worth of phone messages in a week, or if I spend more than 10 minutes reading and responding to emails from you during a given week I will bill you on a prorated basis for that time.

    If I receive a subpoena related to individual(s) who are receiving counseling and it requires any action from me, I will charge an hourly rate of $400.00 from the moment I perform the services as required by me under the subpoena until it is concluded. Payment of my fee will be due within 5 days of the services performed pursuant to the subpoena. Payment to me is not dependent upon my findings or on the outcome of any legal actions. Payment simply constitutes a fee for the time spent complying with the subpoena.

    If you have insurance, you are responsible for providing us with the information we need to send in your bill. You must pay your deductible at the beginning of each calendar year if it applies and any co-payment at each session. Meadows Counseling Center, LLC will bill directly to your insurance company via electronic means for you. You must provide us with your complete insurance identification information, and the complete address of the insurance company. If a check is mailed to you to cover your balance due, you are responsible for paying me that amount at the time of our next appointment. If the insurance over-pays me, we will credit it to your account or refund it to you if you would prefer that.

    I have read this statement, had sufficient time to be sure that I considered it carefully, asked any questions that I needed to, and understand it. I understand the limits to confidentiality required by law. I consent to the use of a diagnosis in billing, and to release of that information and other information necessary to complete the billing process. I agree to pay the fee of $100.00 per session if I do not use an insurance company. I understand my rights and responsibilities as a client, and my therapist’s responsibilities to me. I agree to undertake therapy at Meadows Counseling Center.

    Contact information

    4650 Center Street ∙ Deer Park TX 77536 ∙ Phone 832-794-0646 ∙ Fax 281-867-0194