Susan J. Poole, PhD
APPOINTMENTS: Your appointment time is held exclusively for you. Therapy appointments last for 45 minutes. It is important that you arrive on time for your appointment, as it cannot be extended. If you are unable to keep your appointment for any reason, please contact the office at least 24 hours in advance to cancel or reschedule; otherwise, you will be charged the $50 for the missed session. This office does not give reminder calls for appointments. It is your responsibility to remember and keep track of your appointments. As insurance will not pay for missed sessions, you will be responsible for the charge.
CREDENTIALS: I am a psychologist licensed in the State of Washington. I earned a doctoral degree (Ph.D.) in psychology from Washington State University in 1998 and completed an internship at Duke University in counseling psychology. As a member of the American Psychological Association and as a psychologist licensed by the State of Washington, I work to uphold the highest ethical standards.
PROCESS OF THERAPY: I view psychotherapy as a powerful process with the potential to change unhealthy life patterns, reduce uncomfortable emotional symptoms, restore a feeling of control over life and improve self-esteem. To accomplish your goals, you and I will need to form a partnership: I will do my best to provide effective treatment, and you will need to make personal commitment to try new things. You will assume a good deal of responsibility –and credit- for our ultimate success. Unlike medicine, in which you simply describe your symptoms and the doctor cures your illness, psychotherapy challenges you to begin actively changing the way you think about and respond to life. I practice an eclectic therapeutic orientation and will endeavor to explain to you the kinds of treatments that are typically used, approaches to assessment, and length and course of treatment for the issues you present.
There are no guarantees that the results of any evaluation or therapy will conform to your every expectation. I make no promises to determine any particular diagnosis or to reach any particular conclusion for an evaluation. In fact, effective psychotherapy is sometimes confusing, and it is sometimes emotionally painful. Effective treatment and accurate assessment depend to a significant degree on your openness, your commitment to change, and your collaboration.
EMERGENCY CALLS: An Answering Service takes all emergency calls outside of regular business hours. This service will attempt to locate me in the event of an emergency and will contact the on-call psychologist if I am not available. After hours calls are typically charged a fee based on a prorated amount for the length of the call. You may also call the crisis line at: 253-798-4333 (Pierce County) or 206-461-3222 (King County).
FEES: My fees are $245 for the initial appointment and $215 for each subsequent appointment. Fees for testing, reports, letters, review of records, and phone calls will be based on the amount of time required, at a rate of $215 per hour.
BILLING AND PAYMENTS: Patients, or their responsible legal guardian, are responsible for their accounts and are expected to pay their bill when due, whether medical insurance pays for a portion or not, including charges for evaluation, printed materials, reports, letters, consultations and telephone calls. A finance charge of 1% per month may be added to any balance not paid within 60 days after the charge was incurred. When 90 days have passed without a payment or prior arrangement with me, accounts may be sent for collection and the patient or legal guardian may be responsible for any additional legal and/or collection agency charges. Results of evaluation or reports may not be released until accounts are paid in full. I understand that this is an expensive treatment and I am prepared to arrange an extended payment plan. This entails a written agreement to pay a fixed amount regularly each month until the balance is paid. If regular payments stop, the balance will be considered delinquent, and finance charges and collection procedures may be instituted.
Bills are sent out monthly and detail the dates of visits, the type of service provided, whether your insurance company had been billed for that visit, and all payments made into your account. If you have any questions about your bill, please ask me or our billing department.
You are expected to pay for each session at the time it is held, unless we agree otherwise or unless you have insurance coverage. If you have insurance coverage you are expected to pay your co-pay at the time of each appointment. The co-pay for mental health is often different from that for other medical visits. If you are uncertain about your co-pay I encourage you to contact your insurer. Until you know for certain what your co-pay is, I would ask that you pay 20% of my fee (e.g., $30) at the time of each appointment.
INSURANCE: I am a contracted provider for many, but not all, local insurance companies. You should be sure to check with your insurer and my intake office to learn whether I am a provider for your plan. You should also learn whether you need a referral or preauthorization in order to be eligible for your mental health benefit, whether you have a separate annual deductible for mental health, and whether your mental health benefit has a maximum yearly number of visits or a maximum yearly dollar amount. My billing department will submit claims to insurance companies that I am contracted with. In order for this to occur you must complete the insurance portion of the “Patient Information” form that was given to you with this office policy; you also need to provide a copy of your insurance card.
CHANGES TO THIS OFFICE POLICY: From time to time I may change the business policies described in this document; I will attempt to notify you of relevant changes.
INFORMED CONSENT: Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
INFORMED CONSENT FOR ADULTS: I hereby authorize Susan J. Poole, Ph.D., a licensed psychologist, to render psychological services to ______. This authorization constitutes informed consent without exception. I have read and understand the office policy statement and notice of privacy practices and have received a copy of this office policy for myself.
Signature Date
INFORMED CONSENT FOR MINORS: Washington State Law recognizes the right of 13-17 year-olds to consent to their own treatment, which also protects their rights to confidentiality. When working with adolescents I believe that it is important to work with the family while preserving the adolescent’s right to confidentiality. Treatment is typically impeded if an adolescent does not feel that s/he has a private place to talk about concerns. Thus, I typically seek the adolescent’s consent before speaking with parents. Of course, the same limits to confidentiality that apply to adults (listed in the following section) also apply to minors.
I hereby authorize Susan J. Poole, Ph.D., a licensed psychologist, to render psychological
services to ______. This authorization constitutes informed consent without exception. I have read and understand the office policy statement and notice of privacy practices and have received a copy of this office policy for myself.
Patient Signature Date
Parent/Guardian Signature Date
CONFIDENTIALITY & MEDICAL RECORDS
This document contains important information about your rights regarding confidentiality and your medical records. Please read it carefully, as you did my office policy. Make a note of any questions you might have so we can discuss them. When you sign this document, it will represent an agreement between us.
CONFIDENTIALITY: The State of Washington, and the federal Health Insurance Portability and Accountability Act (HIPAA), allow most issues discussed with me to remain confidential. These laws protect your right to privacy. For example, the information that I record in my psychotherapy notes is protected by HIPAA and cannot be used or disclosed without your specific, written authorization (there are a few exceptions; please see below).
Other health information is provided somewhat less protection by state and federal law. Examples include information pertaining to medication prescription and monitoring, counseling session start and stop times, dates of treatment, results of clinical tests, and summaries of your diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. This information is called Protected Health Information (PHI) because it is still safeguarded and can be released only in limited circumstances and for specific reasons. In particular it may be used or disclosed for purposes of treatment, payment, or health care operations.
– Treatment involves the provision, coordination or management of your health care and other services related to your health care. An example of treatment would be my consulting with another health care provider, such as your family physician or another counselor.
- Payment involves the reimbursement of RA for your healthcare. This can include the disclosure of your PHI to your health insurer, when required, to obtain reimbursement or to determine benefit 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.
By signing this document you provide your consent for me to use and disclose your PHI for these three purposes.
There are some instances in which your right to confidentiality is automatically waived. Any or all of your health information, including anything in my psychotherapy notes, may be released, even without your consent or written authorization, in the following circumstances.
§ If I become aware that you or another person may be abusing, exploiting or neglecting a child under age 18, a dependent adult, a developmentally disabled person, or an elderly person, a report must be made to the appropriate authorities (RCW 26.44).
§ If you become a danger to others, I must protect the other person(s) and you by warning the other person(s) at risk and report the danger to the appropriate authorities (RCW 71.05.120).
§ If you become mentally ill and become unable to take care of your basic needs or become a danger to yourself or others and also refuse treatment, I must report your condition to the authorities (RCW 71.05).
§ If you tell me that you are suffering from HIV-related illness and do not have a physician providing for your care, I must report the identities of your IV drug-using or sexual partner(s) to the local health care officer (WAC 248-100-072).
§ If my professional licensing board subpoenas me as part of its investigations, hearings or proceedings relating to the discipline, issuance or denial of licensure of state licensed professionals, I must comply with its orders and disclose your relevant mental health information (RCW 18.130.180).
§ 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 court order signed by a judge. 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 (RCW 18.83.110, RCW 71.05.390, and RCW 71.05.630).
§ If you file a worker’s compensation claim, with certain exceptions, I must make available upon request, at any stage of the proceedings, all mental health information in my possession relevant to that particular injury (in the opinion of the Washington Department of Labor and Industries) to your employer, your representative, and the Washington Department of Labor and Industries (RCW 51.36.110).
In all other instances, beyond those listed above, I will obtain an authorization from you before using or disclosing any of your health information. A valid authorization must be written and signed by you and specify the recipient of the information (including the institutional affiliation of this individual) and the particular information to be used or disclosed. For example, if you would like me to speak with a family member, you can complete an “Authorization to Disclose” form. A written authorization is valid for no longer than 90 days from the date you sign it. You may revoke an authorization at any time, as long as the revocation is in writing. You may not revoke an authorization for information that has already been disclosed based on that authorization. Neither may you revoke an authorization that was obtained as a condition of obtaining insurance coverage.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION: You have the following rights concerning the health information that I maintain about you (for as long as your records are maintained – a minimum of 7 years).
· Right to Request Restrictions –You may request restrictions on certain uses and disclosures of PHI. I may deny your request under certain circumstances, but in some cases you may have this decision reviewed.
· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – For example, if you did not want your family to know that you are in treatment, you could request that we send your bills to another address.