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Montesinos Counseling Services, LLC, 4720 Salisbury Road, Suite 242, Jacksonville, FL 32256
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. OUR PLEDGE REGARDING HEALTH INFORMATION: We understand that health information about you and your health care is personal. We are committed to safeguarding your protected health information (PHI). PHI constitutes the information we maintain in records of the care and services you receive from our practice that can identify you. This includes information about your past, present, or future health or condition, providing health care services to you, and the payment for such health care. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our mental health care practice. This notice will tell you how we may use and disclose your health information. We also describe your rights to the health information we keep about you and our obligations regarding using and disclosing your health information. We are required by law to:
Ensure health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices concerning health information.
Follow the terms of the notice that is currently in effect.
We can change the terms of this Notice, which will apply to all information we have about you. The new Notice will be available in our office, our website, and the client portal if a change is made.
II. HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that we use and disclose health information. For each category of uses or disclosures, we will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all the ways we are permitted to use and disclose information will fall within one of the categories. Generally, using PHI means sharing, applying, utilizing, examining, or analyzing information within our practice. The disclosure of PHI means releasing, transferring, giving, or otherwise revealing it to a third party outside our practice.
Uses and Disclosures Related to Treatment, Payment, or Healthcare Operations Do Not Require Your Prior Written Consent
Federal privacy rules (regulations) allow healthcare providers who have a direct treatment relationship with the patient/client to use or disclose the patient/client’s personal health information without the patient’s written authorization to carry out the healthcare provider’s treatment, payment, or healthcare operations.
For Treatment: We can use your PHI within our practice to provide you with mental health treatment. This includes consultation with clinical supervisors or other treatment team members. We may disclose your PHI to physicians, psychiatrists, psychologists, and licensed healthcare providers who provide you with healthcare services or are otherwise involved in your care. However, we prefer to have your authorization. For example, if a clinician were to consult with another licensed healthcare provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, to assist the clinician in diagnosing and treating your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard because therapists and other health care providers need access to the full record and complete information to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care providers with a third party, consultations between providers, and patient referrals for health care from one health care provider to another.
To obtain payment for treatment: We may use and disclose your PHI to bill and collect payment for our treatment and services. For example, we might send your PHI to your insurance company or health plan to get paid for the health care services that we have provided to you. We could also provide your PHI to business associates, such as billing companies, claims processing companies, and others who process health care claims for my office.
We may disclose your PHI for healthcare operations to facilitate our practice's efficient and correct operation. For example, to maintain quality control, we might use your PHI to evaluate the quality of healthcare services you have received. Other examples of healthcare operations are business-related matters such as audits, administrative tasks and services, and disclosing PHI to our attorneys or other consultants to ensure we comply with applicable laws.
Other disclosures: Your consent isn’t required if you need emergency treatment, provided we attempt to get your consent after treatment is rendered. If we try to get your consent, but you cannot communicate with me (for example, if you are unconscious or in severe pain), but we think that you would consent to such treatment if you could, we may disclose your PHI.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. Some of our providers keep “psychotherapy notes,” as that term is defined in 45 CFR § 164.501. Any use or disclosure of such notes requires your authorization unless the use or disclosure is: a) For use in treating you. b) For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy. c) For use in defending ourselves in legal proceedings instituted by you. d) For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA. e) Required by law, and the use or disclosure is limited to the requirements of such law. f) Required by law for certain health oversight activities about the originator of the psychotherapy notes. g) Required by a coroner who is performing duties authorized by law, and h) Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. We WILL NOT use or disclose your PHI for marketing purposes.
Sale of PHI. We WILL NOT sell your PHI in the regular course of our business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, we can use and disclose your PHI without your authorization for the following reasons:
When disclosure is required by state or federal law, the use or disclosure complies with and is limited to the relevant requirements of such law.
For public health activities, including reporting suspected child, elder, or dependent adult abuse or preventing or reducing a serious threat to anyone’s health or safety.
For efforts to address risks of danger to self or others, including if you are experiencing a mental or emotional condition causing you to pose a serious risk of danger to yourself or the person or property of others, and if we determine that disclosure is necessary to prevent the threatened danger.
For health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain Authorization from you before doing so.
For law enforcement purposes, including reporting crimes occurring on my premises.
To coroners or medical examiners when such individuals perform duties authorized by law.
For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition. All research projects are subject to a special review process and the confidentiality requirements of state and federal law.
Specialized government functions, including ensuring the proper execution of military missions, protecting the President of the United States, conducting intelligence or counter-intelligence operations, or helping to ensure the safety of those working within or housed in correctional institutions.
For workers' compensation purposes. Although we prefer obtaining Authorization from you, we may provide your PHI to comply with workers' compensation laws.
Disclosures to Business Associates. We may disclose PHI about you to business associates for services they may provide to assist us in providing quality health care. To ensure the privacy of your PHI, we require all business associates to apply appropriate safeguards to any PHI they receive or create.
Appointment reminders and health-related benefits or services. We may use and disclose your PHI to contact you to remind you that you have an appointment with our office. We may also use and disclose your PHI to tell you about treatment alternatives or other healthcare services or benefits that we offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
Disclosures to family, friends, or others. We may provide your PHI to a family member, friend, or another person you indicate is involved in your care or the payment for your health care unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergencies.
VI. YOU HAVE THE FOLLOWING RIGHTS CONCERNING YOUR PHI:
The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask me not to use or disclose certain PHI for treatment, payment, or health care operations purposes. I am not required to agree to your request, and I may say “no” if I believe it would affect your health care.
The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service you have paid for out-of-pocket in full.
The Right to Choose How I Send PHI to You. You have the right to ask me to contact you in a specific way (for example, by home or office phone or by an alternate method such as via e-mail instead of by regular mail) or to send mail to a different address, and I will agree to all reasonable requests.
The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information I have about you. I will provide you with a copy of your record or a summary of it (if you agree to receive a summary) within 30 days of receiving your written request, and I may charge a reasonable, cost-based fee for doing so.
The Right to Get a List of the Disclosures I Have Made. You have the right to request a list of instances in which I have disclosed your PHI for purposes other than treatment, payment, and healthcare operations for which you provided me with Authorization. I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I will give you will include disclosures made in the last six years unless you request a shorter time. I will provide the list to you at no charge, but if you make more than one request in the same year, I will charge you a reasonable cost-based fee for each additional request.
The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI or that a piece of important information is missing, you have the right to request that I correct the existing information or add the missing information. I may say “no” to your request, but I will tell you why in writing within 60 days of receiving your request.
The Right to Get a Paper or Electronic Copy of this Notice. You have the right to get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy.
VII. COMPLAINTS.
If, in your opinion, we may have violated your privacy rights, or if you object to a decision we made about access to your PHI, you are entitled to file a complaint with the person listed in Section VIII below. You may also send a written complaint to the Department of Health and Human Services Secretary at 200 Independence Avenue S.W., Washington, D.C. 20201. If you file a complaint about our privacy practices, we will take no retaliatory action against you.
VIII. CONTACT INFORMATION FOR QUESTIONS ABOUT THIS NOTICE TO ISSUE A COMPLAINT ABOUT THESE PRIVACY PRACTICES.
If you have any questions about this notice or any complaints about these privacy practices or would like to know how to file a complaint with the Secretary of the DHHS, don't hesitate to get in touch with Steven Montesinos, LMHC, Privacy Officer, Owner, Montesinos Counseling Services, LLC, 4720 Salisbury Road, Suite 242, Jacksonville, FL 32256 Phone: 904-701-4662, steven@montesinoscounseling.com
EFFECTIVE DATE OF THIS NOTICE
This notice went into effect on May 6, 2018
Acknowledgment of Receipt of Privacy Notice
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights to use and disclose your protected health information. By checking the box below, you acknowledge that you have received a copy of the HIPAA Notice of Privacy Practices.
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As a current or prospective client, you understand that you can text us STOP at any time to opt out of receiving SMS text messages from us. You can text us HELP at any time to receive help.
You understand that the messaging frequency may vary.
Your mobile information will not be shared with any third parties/affiliates for marketing/promotional purposes. All policies are followed as per CTIA guidelines 5.2.1. At any time if you want your information to be removed, you can contact us via our email address or regular mail.
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Montesinos Counseling Services, LLC, 4720 Salisbury Road, Suite 242, Jacksonville, FL 32256
INFORMED CONSENT FOR PSYCHOTHERAPY & PRACTICE POLICIES
GENERAL INFORMATION
The therapeutic relationship is characterized by its deeply personal nature as well as being a professional agreement. It is essential that we establish a clear understanding of how the therapeutic relationship will function and what each party can expect. This consent document aims to provide a comprehensive framework for engagement in the therapeutic process. We invite open dialogue regarding any aspect of this document and welcome your questions anytime.
THE THERAPEUTIC PROCESS
Pursuing therapy is a significant step toward personal growth and well-being. The success of therapy is largely dependent on active involvement and commitment to the process. Engaging in therapy can sometimes be challenging and uncomfortable, as it may involve recalling distressing events and confronting associated emotions. While we can not offer guaranteed outcomes regarding the therapeutic process, our providers pledge to offer you support and assistance in clarifying and achieving your personal goals.
CONFIDENTIALITY
Confidentiality is a fundamental aspect of the therapeutic relationship. All information discussed in sessions, as well as relevant materials related to your treatment, will be held in strict confidence by our providers, except under the following circumstances:
If there is a direct threat of harm to yourself or others, including suicide or violence.
If there is reasonable suspicion of abuse or neglect involving minors, the elderly, or disabled individuals.
If a court orders the release of information through a legitimate subpoena.
When consulting with other healthcare professionals to enhance your treatment, anonymity will be preserved.
APPOINTMENTS AND CANCELLATIONS
To help us provide consistent and timely care to all our clients, we kindly request that you provide at least 24 hours notice if you need to cancel or reschedule an appointment. This allows us the opportunity to offer your appointment slot to someone else who may be in need of our services. In the event that an appointment is missed or canceled without a 24-hour notice, a fee of $50 will be applied. This fee helps us maintain the quality and accessibility of our services. Should such a situation occur, the fee will be processed using the payment method we have on file for you. Insurance does not cover missed appointment or late cancellation fees.
Our standard individual psychotherapy sessions are 50 to 55 minutes in duration. If you arrive late, we may not be able to extend your session time, and late arrival will likely result in a shorter session. The fee for each session is $155, and payment is processed after each session using the payment method on file.
Should any payment be returned due to insufficient funds or other banking issues, a $10.00 service charge will be applied.
INSURANCE AND BILLING
Our practice accepts several insurance plans, including Aetna, United Healthcare, UMR, Cigna, Oscar, Oxford Health, Optum, and Tricare Standard and Select. Please note that not every provider at our practice accepts each of these plans. We recommend checking our website or contacting our office to ensure that the provider you are scheduled with accepts your specific insurance.
Additionally, if you have a Tricare plan, please be aware that the providers who accept Tricare are certified non-network providers. This may mean you have a small deductible to reach before your plan will cover a portion of the cost of services through our practice.
Headway, a third-party claims processor, manages some of our insurance billing. If you have an insurance plan that we process through Headway, you will receive a registration email and communication from Headway to manage your insurance and payment details. While we do not control the rates charged by Headway, we are committed to addressing any concerns you may have regarding their billing practices. If you have a concern about Headway and their billing, please notify our office so we can address your concerns. You are also welcome to contact them directly by visiting their website: https://headway.co/.
If you don’t have any of the health insurance plans that we accept, we can offer documentation for filing out-of-network insurance claims if you would like for counseling sessions to be applied to your yearly out-of-network deductible or if you are eligible for partial reimbursement of out-of-network care through your insurance policy. We cannot guarantee that your insurance will reimburse you for out-of-network care, so we encourage you to contact them to review your benefits.
For those who are uninsured or choose not to use insurance for services, we provide a "Good Faith Estimate" upon request, detailing the expected costs of your mental health care.
STAFF INTERNS AND SUPERVISION
Some of our providers hold registered intern licenses, which are considered provisional licenses in Florida, and are working toward full licensure. These providers are graduates who have undergone extensive training and supervision to be eligible to gain the additional experience required for licensure in the state. They are supervised by a registered supervisor and an additional staff member at our office to ensure the highest quality of care. If you have any concerns about your care while working with an intern, please contact our office. Providing high-quality care is our priority, and we are also committed to training the mental health professionals of the future.
TELECOMMUNICATION
For routine communication, we encourage you to contact our office by phone or through the secure online client portal. If we are unavailable to take your call immediately, please leave a voicemail, and we will endeavor to return your call within 48 hours, excluding weekends and holidays. Please be aware that we are not equipped to provide immediate crisis response, and in case of an emergency, you should call 911 or visit the nearest emergency room.
The confidentiality of electronic communication, such as email and text messaging, cannot be guaranteed. These forms of communication should not be used to share sensitive therapeutic content. For discussions related to your therapy, please use secure methods such as the client portal or phone communication.
TECHNOLOGY USE
Our practice utilizes a HIPAA-compliant Electronic Health Record (EHR) system for the secure management of client records and to conduct telehealth sessions. We also employ audio transcription software to enhance the accuracy and efficiency of documenting clinical sessions. This software adheres to HIPAA standards and does not store audio recordings beyond their immediate use for transcription purposes.
In addition, we use medical-grade artificial intelligence (AI) technology to support clinical documentation and treatment planning. This AI technology processes information in real time and is designed to comply with HIPAA regulations, ensuring your data is not stored, transmitted, or accessed beyond the immediate need for treatment.
SOCIAL MEDIA
Our practice and its providers maintain professional boundaries with clients on social media platforms. We do not accept friend or contact requests from current or former clients on any personal social networking site. This policy is in place to safeguard our mutual confidentiality and privacy and maintain the integrity of the therapeutic relationship,
While you are welcome to follow or interact with our practice's professional social media accounts, we advise doing so with discretion to protect your privacy.
Should there be a therapeutic reason to review your social media interactions as part of your treatment, such as examining digital behavior patterns or the impact of social media on your well-being, please bring this content to your sessions. Our providers will not review your online activities without your explicit consent and direction.
Please be aware that social media platforms may use algorithms that could suggest connections to our practice or other clients based on your interactions. We have no control over these platform features, and we recommend you adjust your privacy settings to minimize such occurrences and protect your confidentiality.
MINORS
If you are a minor, your parents or legal guardians may have the legal right to access certain information about your therapy. We will discuss with you and your parents or guardians the types of information that might be appropriate for them to know and which issues are more appropriately kept private. Our goal is to promote your privacy and the therapeutic relationship while also considering legal requirements and the rights of parents or guardians.
HEALTH AND SAFETY
Our practice is dedicated to maintaining a safe and healthy environment for all clients and staff. We adhere to public health guidelines and best practices to help prevent the spread of communicable diseases. We kindly ask that you use discretion and consider the well-being of others when deciding to attend an in-person session.
If you are experiencing symptoms of any illness, have been exposed to someone who is sick, or are not feeling well, we encourage you to reschedule your appointment or opt for a telehealth session if available. This approach helps protect our community and ensures that we can continue to provide care in the safest manner possible.
DISCHARGE PROCESS
There are several reasons why we may eventually end our professional relationship, such as lack of benefit, preference for another provider, or need for specialized care. If we initiate discharge of care, we will first discuss the reasons for discharge with you and, if you request, provide you with a list of other qualified providers. We will also extend the discharge process length, if necessary, based on your treatment needs, including continuing to provide support for a time-limited period after you have been notified of the end of our treatment relationship.
Non-payment, recurring non-attendance, or disrespectful communication can also result in discharge, with efforts made to provide you with referrals.
We will consider the professional relationship discontinued if no appointments are scheduled for eight consecutive weeks without prior agreement. If you wish to resume therapy after this period, it may require waiting for an opening.