Policy and Procedures: Information Sheet

Please read through this in its entirety - these are the bones that create the relationship between client and therapist. If you have any questions, please do not hesitate to ask for clarification!!!

I can provide encrypted email and video/chat access if you wish to use that - you may register for this and other online services via this link: https://DeeDunnLPC.SecurePatientArea.com

Technology Assisted Counseling (TAC)

Consent, Policies & Agreement

This form is in addition to the regular Policy and Procedure, Financial Agreement, HIPAA notice form and any other Informed Consent forms for therapeutic or treatment. This specific form must be signed in order for you to receive any form of technology assisted counseling (TAC) sessions.

TAC incorporates secure communications through a client/patient portal, phone and/or video counseling. This form provides you with information about the benefits, limitations and logistics of TAC. If you have any questions that are not covered by this info sheet, please let me know. Do not sign this form until you have all the information you need to make an informed decision.

Benefits of TAC:

Increases your choice of service providers

More convenient options for counseling to fit your location, schedule..

Reduces extra costs of travel, time away from work or family.

May improve your access to mental health care services by providing easier and/or faster links to mental health care providers

Enables increased availability of services to clients who may be homebound, quarantined, who have limited mobility or for whom transportation options are limited.

Limitations of TAC:

It is important to understand that there are limitations to TAC counseling that can affect the quality of the session and your experience of the session. These limitations include but are not limited to the following:

I may not be able to see you, your body language, or non-verbal reactions to what we are discussing, so I may not be aware of how you are responding or reacting unless you share that verbally.

Due to technology issues, I may not hear all of what you are saying and so I may ask you to repeat things you have said, even though that might be uncomfortable for you to do.

Technology might fail before or during the TAC counseling sessions. In the event that we lose our connection, I will wait for you to "reload" and restart your connection, and if that doesn't work we will move to a Zoom platform (I will email you a link and a password which is specific to you and you alone).  If your connection is not strong enough to support contact, we will not be able to complete the session, but you will be charged for the time, as it is your responsibility to be in the right place at the right time, just as if you were coming to any other office setting.

Although every effort is being made by you and by me to reduce confidentiality breaches, breaches may occur for various reasons. At the start of each session I will ask you to confirm that you are in a secure, safe and confidential space. 

To reduce the effect of these limitations, I may ask you to describe how you are feeling, thinking and/or acting in more detail than I would during an in-office setting. You might also feel a need to describe, explain or share your feelings, thoughts and/or actions in more detail than you might have felt during an in-office setting.

Logistics:

You will be asked to register on a secure portal prior to beginning sessions. Through this portal you will be able to send secure emails, store your personal, insurance and payment information, keep a private journal, make payments and print out receipts for insurance or HSA reimbursements, if you choose to do so. You will be able to check the calendar for your scheduled appointments. You can choose options to receive reminders for appointments, and we can use this portal for video or chat sessions, technology signals or bandwidth permitting.

All TAC sessions will be started from a secure and HIPAA compliant setting. Any link you receive will be available only to you, has a specific ID number and password that only you should know. Do not share this information with anyone. Ever. In the event that I cannot see or hear you, and need to verify you are you, I will ask you to give me information that only you and I would know.

I will be in a secure and HIPAA compliant location, and you are expected to be in a private location, free from distractions, and where you can speak freely without being overheard or interrupted by others. Please begin each session by verifying your real-time physical address/location. I may ask you to pan your camera around the room so I can see that you are safe, and that you are in a private, secure space. Every effort must be made, by me, and by you, to protect your confidentiality. If I cannot be assured of your privacy I may end the session; you would be responsible for the charges incurred for that entire session.

I recommend you use headphones and a microphone to facilitate your privacy; please test out your equipment before sessions begin. Wifi signals do not always cooperate with ancillary equipment, phone jacks are not necessary the same as on your computer or tablet, and you may find that there is an optimum configuration.

In the event that our connection is interrupted, dropped, or degrades, I will wait for you to refresh your browser or page. If that is not possible, I will wait for you to call me and we will continue as is appropriate. I will help you troubleshoot the problem if you call me. If we cannot solve the technology glitch, we will continue on via phone or chat or whatever makes sense given the situation.

By State laws, best practice and Ethics guidelines, I will only provide services in States where I am licensed. That means you must reside in the State where I am licensed.

Recording of sessions:

Please note that recording, screenshots, etc of any kind, in any session is not permitted without express permission by BOTH you and me. Breaking this agreement is grounds for termination of the client-therapist relationship.

Payment for Services:

Payment for any form of session is due prior to the start of the session. I will charge your card on file or send you an invoice. Please complete this prior to each session.

Cancellation policy:

Continuity is important to get the results you want. If you must cancel a session, please do so at least 24 hours before your session. Short cancellations are charged at the full rate for that session and will not be submitted for insurance payment. Cancellations may be made by phone, or by secure email, or by text. I will acknowledge your request. If you do not receive an acknowledgment, it means I did not get your request and that means you are still on the schedule and will be responsible for charges.

Please note that if you are going to be late to session, or your battery died, or your dog ate your phone, or your family showed up and there is no place private to talk - you will still be charged for the time. Please plan ahead and make arrangements you need to be successful in your goal to be available and present for your sessions.

HIPAA NOTICE OF PRIVACY PRACTICES

I. 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.

II. IT IS MY LEGAL DUTY TO SAFEGUARD YOUR PROTECTED HEALTH INFORMATION (PHI).
By law I am required to insure that your PHI is kept private. The PHI is information created or noted by me that can be
used to identify you. It contains data about your past, present, or future health or condition, the provision of health care
services to you, or the payment for such health care. I am required to provide you with this Notice about my privacy
procedures. This Notice explains when, why, and how I would use and/or disclose your PHI. Use of PHI means when I
share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or
otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI
than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required
to follow the privacy practices described in this Notice.
Please note that I reserve the right to change the terms of this Notice and my privacy policies (as allowed by law) at any
time.

III. HOW I WILL USE AND DISCLOSE YOUR PHI.
I will use and disclose your PHI for many different reasons. Some of the uses or disclosures will require your prior written
authorization; others, however, will not. Below are the different categories of uses and disclosures, with examples.

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior
Written Consent.

I may use and disclose your PHI without your consent for the following reasons:

1. For treatment. I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care
providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist
is treating you, I may disclose your PHI to her/him in order to coordinate your care.
2. For health care operations. I may disclose your PHI to facilitate the efficient and correct operation of my practice.
Examples: Quality control - I might use your PHI in the evaluation of the quality of health care services that you have
received or to evaluate the performance of the health care professionals who provided you with these services. I may
also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with
applicable laws.
3. To obtain payment for treatment. I may use and disclose your PHI to bill and collect payment for the treatment and
services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get
payment for the health care services that I have provided to you. I could also provide your PHI to business associates,
such as billing companies, claims processing companies, and others that process health care claims for my office.
4. Other disclosures. Examples: Your consent isn't required if you need emergency treatment provided that I attempt to
get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to
communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such
treatment if you could, I may disclose your PHI.

B. Other Uses/Disclosures That Do Not Require Your Consent:

I maybe required by law to use and/or disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or,
law enforcement. Example: I may make a disclosure to the appropriate officials when a law requires me to report
information to government agencies, law enforcement personnel and/or in an administrative proceeding.

2. Abuse or Neglect: If I suspect abuse or neglect of a child or elder, I am mandated to make a report to the appropriate
public authorities.

3. Harm to Self or Others: If I suspect you are in imminent danger of harming yourself or someone else, I am mandated
to make a report to the person at risk, or to the public authorities, including law enforcement personnel. This includes
statements you make to me about your plans or intentions to harm another reasonably identifiable victim(s) or the
public.

4. For health oversight activities. Example: I may be required to provide information to assist the government in the
course of an investigation or inspection of a health care organization or provider.

5. For specific government functions. Examples: I may disclose PHI of military personnel and veterans under certain
circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the President of the
United States or assisting with intelligence operations.

6. For research purposes. In certain circumstances, I may provide PHI in order to conduct medical research.

7. For Workers' Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws.

8. Appointment reminders and health related benefits or services. Examples: I may use PHI to provide appointment
reminders. I may use PHI to give you information about alternative treatment options, or other health care services or
benefits I offer.

9. I am permitted to contact you, without your prior authorization, to provide appointment reminders or
information about alternative or other heath-related benefits and services that may be of interest to you.

10. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law.
Example: When compelled by U.S. Secretary of Health and Human Services to investigate or assess my compliance
with HIPAA regulations.

11. If disclosure is otherwise specifically required by law.

C. You Have The Right To Reject:

Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or other individual who
you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or
in part. Retroactive consent may be obtained in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization.
In any other situation not described in Sections IIIA, IIIB, and IIIC above, I will request your written authorization before
using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke
that authorization, in writing, to stop any future uses and disclosures of your PHI by me.

IV. WHAT RIGHTS YOU HAVE REGARDING YOUR PHI
These are your rights with respect to your PHI:

A. The Right to See and Get Copies of Your PHI.

In general, you have the right to see your PHI that is in my possession, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request.

Under certain circumstances, I may feel I must deny your request, but if I do, I will give you, in writing, the reasons
for the denial. I will also explain your right to have my denial reviewed. If you ask for copies of your PHI, I will charge you
for reasonable expenses associated with your request.

B. The Right to Request Limits on Uses and Disclosures of Your PHI.

You have the right to ask that I limit how I use and disclose your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make.

C. The Right to Choose How I Send Your PHI to You.

It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via email instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience.

D. The Right to Get a List of the Disclosures I Have Made.

You are entitled to a list of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented, i.e., those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, to corrections or law enforcement personnel, or disclosures made before April 15, 2003. After
April 15, 2003, disclosure records will be held for six years. I will respond to your request for an accounting of disclosures
within 60 days of receiving your request. The list I give you will include disclosures made in the previous six years  unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than one request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.
 

E. The Right to Amend Your PHI.

If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request.

I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed,
(c) not part of my records, or (d) written by someone other than me. My denial must be in writing and must state the reasons
for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written
objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If
I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made,
and I will advise all others who need to know about the change(s) to your PHI.

F. The Right to Get This Notice by Email

You have the right to get this notice by email. You have the right to request a paper copy of it, as well.

V. WHAT ABOUT THERAPY NOTES?
I am allowed to keep separate notes related to the therapy session - these psychotherapy notes include specific information
you have shared in the session such as thoughts or attitudes, art work, or ideas and plans, that help me provide treatment to
you BUT people and agencies outside the session do NOT need to know in order to provide their service to you. These
records are confidential but are not considered PHI. They may be released only to another professionals such as a
counselor, psychologist or to the court only with specific consent from you, OR by Court Order.

I am allowed to use or disclose NON-IDENTIFYING information from these notes to get clinical review, supervision or training for myself, or to
provide training to other mental health professionals.

In situations of SAFETY, I may be REQUIRED to use parts of this information WITH your PHI to protect you or others from harm. Examples of this include disclosing specific threats or incidents of abuse toward you or by you toward others, information about prenatal exposure to controlled substances, reporting specific misbehavior by a health care provider. In the event of your death, your family may obtain these records.

VI. HOW TO MAKE A COMPLAINT ABOUT MY PRIVACY PRACTICES
If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI,
you are entitled to file a complaint with the person listed in Section VII below. You may also send a written complaint to the
Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W. Washington, D.C. 20201. If
you file a complaint about my privacy practices, I will take no retaliatory action against you.

VII. TO COMPLAIN ABOUT MY (or anyone else's) PRIVACY PRACTICES
If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file
a complaint with the Secretary of the Department of Health and Human Services, please contact me at 540-270-4516 or
write to the address on the letterhead at the beginning of this notice.

VIII. EFFECTIVE DATE OF THIS NOTICE
This notice goes into effect April 14, 2003.

Portal Accounting Policy (v. 7/1/2020)

The purpose of this policy is to provide you with a clear understanding of how charges and payments will be handled electronically. 

When registering on this portal for services, please enter in your credit card information.  Your appointments cannot be booked on the calendar without a card on file.  Because of security measures, I cannot see your card number, but if you "name" the card, I can tell you which card you have on the account.  You can add a new card at any time - please send me an email so I will know which card is the active card.  If you would like a card removed (expired or changed) let me know and I will delete that card - again, naming the cards will be important so I know which card to remove!

Each session on the calendar will automatically generate an invoice and any balance you owe will show up under "Client's Responsibility".  Please to not mistake your balance for the account balance, which is actually the balance your insurance company owes.  If your Client Responsibility amount shows with a minus (eg. -$27.50 or -$300.00)  that means you have a CREDIT and do not need to make any payments. 

If your Client Responsibility balance due is under $50, please DO NOT make a payment - I will process the charges to your card at the end of each month.  The reason for this is simply to reduce my administrative time spent in accounting.  You will, always, have full access to your account statements on this portal, so you can check your balance and credit card payments made at any time.  If you need help with this, let me know. 

Parents:  Your child's account should have your contact information so that you get any relevant communications. 

I have been using the same, offline accounting program since 2000 - "Therapist Helper" (now "Helper"). Not only is it reliable and familiar, but it is also easier for me to use than this portal's online accounting system.  Rather than change over to the online accounting system, I will continue to use what has worked well for 20+ years.  This means I will enter all charges (to you and to insurance) and all payments (from you and from insurance) into my offline, TH program and track everything there.  If you have any questions, please ask. 

If you are using your insurance, you will continue to get the Explanation of Benefits (EOB) from your insurance company, so you will be able to see all the insurance payments made - but that info will not appear on this portal account.

If you are NOT using insurance, then ALL your account transactions will be visible on the portal (as well as being recorded in the offline system) and you can download a full account report from this portal.

If you are having difficulties in getting a statement to print from the portal, let me know.  I understand how challenging online accounting can be!  I will be happy to send you a statement in a .pdf format. 

Thank you for your understanding on this.  I want to put my energy into being your counselor and not into administrative tasks!