Welcome to Solas Behavioral Health PLLC. This document contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.

Please initial each statement after reading.

Thank you for choosing Solas Behavioral Health PLLC as your mental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.


RISK TO THERAPY:

There are certain risks associated with the counseling process that should be understood before work progresses. For example, in counseling, there is a risk that clients will, for a time, experience uncomfortable levels of sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other difficult feelings. Clients may recall unpleasant memories. Relationships are often affected as a result of therapy. Significant relationships may experience varying degrees of tension. This is often most prevalent within family relationships, but may extend beyond into one's social and professional life. Sometimes, a client's problems may temporarily worsen after the beginning of treatment. Most of these risks are to be expected when people are making significant changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not yield the results that you initially desired from it.


CONTACTING THERAPIST and IN CASE OF EMERGENCY:

Therapist may not be immediately available by phone. During regular business hours there is a receptionist that will answer the calls at the 817-268-7050. The best way to contact your therapist is via message through your secure portal. It is the only way to ensure the most confidential means of communication.

In case of a life-threatening emergency, please go to the nearest emergency room or dial 911. In case of an emergency, or if you need immediate assistance for any reason, please call the 24-hour crisis hotline at (214) 828-1000.

Patient calls, after hours, will be returned by your therapist within twenty four hours. Please be advised that telephone consultations are bill at the same rate as office appointments, and may not be covered by insurance.


SCHEDULING APPOINTMENTS:

Patients are seen by appointment only. Appointments may be made by calling the office 817-268-7050 between the hours of 9:00 a.m. and 5:00 p.m Monday through Friday Appointments, or set up on your secure patient portal. They are made according to the schedule of the patient and the therapist usually 50 - 60 minutes in length. You will generally be seen within 10 minutes of your appointment time, although patient needs may, at times, result in a longer delay.


CANCELLATIONS:

Twenty-Four (24) hour notice for appointment changes or cancellations is required, otherwise the usual session fee will be charged. This charge is the sole responsibility of the patient. If an emergency arises that prevents a 24- hour notice, these will be discussed and resolved on an individual basis with our therapist. The office staff cannot resolve this issue. If the office is closed, please leave a message on the answering machine and we will return your call as soon as possible.


FINANCIAL POLICY:

Thank you for choosing Solas Behavioral Health PLLC as your mental health care provider. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require you to read and sign prior to any treatment.

When you agree to participate in counseling services, you also agree to pay for these services whether the outcome is successful or not. Mental health services cannot be guaranteed, although we shall attempt to provide high quality services at all times.

Insurance: Solas Behavioral Health PLLC is an out-of-network provider and does not accept insurance. Solas Behavioral Health PLLC does not file insurance.

Solas Behavioral Health PLLC must emphasize that as mental health care providers, our relationship is with you, not your insurance company. All charges are your responsibility at the time the services are rendered.

Adult Patients: Adult patients are responsible for payments at the time of service.

Minor Patients: The adult accompanying a minor and the parents (or guardians of the minor) are responsible for the payment at the time of service. For unaccompanied minors, non-emergency treatment will not be provided unless payment arrangements have been made prior to the appointment.

Payment for Services Fees are as follows:

(Individuals) $155.00 Each session (50-60 minutes)
(Couples) $155.00
Additional time in 15 minute increments $30.00
Outside Office Work (inpatient visits) $200.00/hr

Outside Office Work (court, collaborative law services)* $700.00/hr *in addition Patient pays all travel and lodging expenses related to legal subpoena, court, collaborative law services with a non refundable retainer fee of $5600.00 will be paid within 24 hours upon receipt of a subpoena, In the event the disclosure of your records or testimony is required by law, it is your responsibility to pay applicable court fees, regardless of whose attorney subpoenas for therapist involvement. Note that Susan M. Cizmas, MA., LPC has no forensic experience and being a master's level counselor would generally not be considered an expert witness.

Written Reports (insurance companies, supervisors, etc.) pro-rated at $35.00
Letters (insurance companies, work) $70.00
Returned check fee per check $25.00
A reasonable fee will be charged for copies of any records requested by the client.
****RATES INCREASE 3% (will round to nearest dollar) ANNUALLY JANUARY 1 OF each NEW YEAR 

* If counseling had stopped for more than three months rates will go to the current rate.

All fees are due and must be paid at the beginning of each session. Payments can be made online before the session begins. Payment is due when services are rendered unless prior arrangements are made. Cash, credit cards, or personal checks are acceptable form for payments. In the event you will be unable to keep an appointment, you must notify Solas Behavioral Health PLLC at least 24 hours in advance at (817)268-7050 or via your patient portal. If the 24 hour noticed is not receive, you will be responsible for paying the full fee for the session you missed. Take note that if it is intended to submit receipts for reimbursement, insurance companies will not reimburse for missed appointments. If you cannot pay for services rendered, services will need to terminate, we will give you a referral list.



CONFIDENTIALITY:

All communications that occur between therapist and patient are held in the strictest confidence. No information will be will be revealed to anyone without written authorization from the patient (or parent/legal guardian if patient is a minor). Under most circumstance, evaluation results and notes from therapy sessions will remain completely confidential. However, under Texas Law, there are several exceptions to this rule of confidentiality. The attached forms will explain this further. The most common exceptions are:

- Suspected abuse of a child, elderly or disabled person by you or anyone you report to your therapist.
- You indicate an intention to harm yourself or another person
- Sexual exploitation by a former or current therapist.
- Cases before a court & law, which your mental health is an issue (i.e. child custody, divorce, personal injury cases).
- Collection of past due charges or fees.

Additional limits to confidentiality include:
- In the case of minors, parents or legal guardians have access to their child's records, unless emancipated.
- Family, marriage, relationship counseling is not legally private and can be subpoenaed. During individual seasons the therapist is not a secret keeper but will encourage open communication between family members. Therapist reserve the right to terminate the counseling relationship, if it is judge a secret to be detrimental to the therapeutic process.
- Therapist may, upon occasion, discuss their cases anonymously with peer professionals for the sole purpose of improving the quality of services provided to the related client

All patients using third parties to provide partial or complete payment of fees should be aware that any and all of the information provided to the paying organization could be made available by that organization to: employers providing the insurance benefits, other insurance companies/agencies requesting the information, and other health care providers that have contact with the insurance company.

I hereby give written permission to fax clinical data to managed care companies, other third party payers, and/or other mental health care professionals.

I hereby give written permission to send a referral acknowledgment to the doctor/person referring you to this office.

Records All of our communications become a part of your clinical record. Adult client records are disposed of 5 years after the file is closed. Minor client records are disposed of 7 years after the client's 18th birthday.


ELECTRONIC HEALTH RECORD (EHR):

Solas Behavioral Health PLLC has implemented an electronic health record (EHR) in part to meet the U.S. Department Health and Human Services initiative to improve health information technology, toward the goal of improving quality of health care. Our EHR integrates your clinical record with appointments, registration, and billing and makes this information available to the clinicians who are involved in your health care. In connection with its electronic communication systems, Solas Behavioral Health PLLC has also implemented and has in place privacy and security policies and procedures to minimize risk of inadvertent or unauthorized disclosure, corruption and/or loss or distortion of data, but as with all record keeping systems, whether paper or digital, some risks remain of loss, inadvertent disclosure or errors in the recorded data. I have read and understand the information provided regarding EHR, have discussed it with my counselor, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine including electronic transfer of medical data to other medical practitioners participating in my medical care. I hereby authorize Solas Behavioral Health PLLC to use EHR in the course of my diagnosis and treatment and consent to the electronic communication of my personal health care information to other entities for treatment, payment or health care operations

Solas Behavioral Health PLLC is offering the patient portal as a convenience to you. The patient portal is a secure web portal that allows you, as a patient, to view your personal journal and to access our online bill pay via the internet. It also allows you to communicate with our office via secure messaging. You may request appointments, and schedule changes. Solas Behavioral Health PLLC reserves the right to suspend or terminate the patient portal at any time and for any reason. I understand that the patient portal will be offered at no charge and acknowledge that communications over the internet using the portal is secure. I also, agree to the policy defined herein for suspension or termination of portal access.


THERAPIST/PATIENT RELATIONSHIP:

The ethical codes of therapists/psychologists prohibit dual relationships between therapists/psychologists and patients. This means that if you ever are a patient, your therapist cannot meet with you for social occasions, personal social media or be involved in any business activities with you other than providing psychological services.

If my legal residence is located outside of the state of Texas or I move out of the state of Texas, I understand that because of the Initial State of Texas rules and regulations I cannot continue my therapy via telephone or any type of social media.

GRIEVANCES:

Grievances As an LPC your therapist is committed to upholding the rules and policies of the Texas LPC Board. If you are not satisfied with your therapist or your treatment, please raise your concerns with your therapist at once. Your therapist will make every effort to hear any complaints you have and to seek solutions collaboratively with you. If you feel that your therapist has treated you unfairly or have has been unethical, you may contact the LPC Supervisor your therapist reports to or you may contact the LPC Board directly at 1-800-942-5540.


TERMINATION:

Counseling is voluntary. Both you and your therapist reserve the right to transfer/terminate services at any time, for any reason. If you would like a referral to a different therapist; your therapist will gladly assist you in finding one.



Thank you for understanding our each portion of the Informed Consent. Please let us know if you have any questions or concerns.

I have read the above and agree to the Financial Policy of Solas Behavioral Health PLLC

NOTICE OF PRIVACY PRACTICES

Your Information
Your Rights
Our Responsibilities

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record
- You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say "yes" to all reasonable requests.


Ask us to limit what we use or share
-
You can ask us not to use or share certain health information for treatment, payment, or our operations.
- We are not required to agree to your request, and we may say "no" if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.
- We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information
- You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice
-
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated
-
You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.


Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
- Include your information in a hospital directory
- Contact you for fundraising efforts
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

- Marketing purposes
- Sale of your information
- Most sharing of psychotherapy notes
In the case of fundraising: - We may contact you for fundraising efforts, but you can tell us not to contact you again.


Our Uses and Disclosures

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

- We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services.
Bill for your services
- We can use and share your health information to bill and get payment from health plans or other entities.
Example: We give information about you to your health insurance plan so it will pay for your services


How else can we use or share your health information? We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.


Help with public health and safety issues

- We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or safety


Do research

- We can use or share your information for health research.


Comply with the law

- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.


Respond to organ and tissue donation requests

- We can share health information about you with organ procurement organizations.


Work with a medical examiner or funeral director

- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.


Address workers' compensation, law enforcement, and other government requests

- We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena.


Our Responsibilities

- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing.
If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of This Notice
We can change the terms of this notice, and the changes will apply to all information we have about you.
The new notice will be available upon request, in our office, and on our web site.

Effective Date: September 23, 2016

Questions and Complaints:

If you have any questions about this notice, please contact:

Solas Behavioral Health PLLC
Susan M. Cizmas, MA., LPC
4209 Gateway, ste 200

Colleyville TX 76034
Phone: 817-268-7050


- We can share health information about you for certain situations such as:
- Preventing disease
- Helping with product recalls
- Reporting adverse reactions to medications
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone's health or safety

- We can use or share your information for health research.

- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

- We can share health information about you with organ procurement organizations.

- We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

- We can use or share health information about you:
- For workers' compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Notice of Privacy Practices (keep pages 1-5 for your reference)



- We can share health information about you in response to a court or administrative order, or in response to a subpoena.