HIPAA & Practice Policies
Jennifer DeSouza, LICSW, CGP
2000 Massachusetts Avenue, Cambridge, MA 02140
617-575-9438
Jenniferdesouzalicsw@protonmail.com
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, Jennifer DeSouza, am a Licensed Independent Social Worker in the State of Massachusetts. I am a member of the National Association of Social Workers (NASW) and adhere to the NASW Code of Ethics.
MY PLEDGE REGARDING HEALTH INFORMATION:
I understand that health information about you and your health care is personal. I am committed to protecting health information about you.
As a licensed mental health provider I am required to keep notes and records regarding your treatment. These records will be stored within my encrypted electronic health record or in an encrypted HIPAA-compliant device or cloud for a minimum of six years following treatment. You are entitled to a copy of your record. Should you choose to request a summary of your full record, you are encouraged to review it with me to provide the opportunity to ask questions and reduce the possibility of misinterpretation.
I 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 this mental health care practice. This notice will tell you about how I may use and disclose health information about you. I also describe your rights to the health information I keep about you and describe certain obligations I have regarding the use and disclosure of your health information. I am required by law to:
Make sure that protected health information (“PHI”) that identifies you is kept private.
Give you this notice of my legal duties and privacy practices with respect to health information.
Follow the terms of the notice that is currently in effect.
I can change the terms of this Notice, and such changes will apply to all information I have about you. The new Notice will be available upon request, in my office and on my website.
II. HOW I MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU: The following categories describe different ways that I use and disclose health information. For each category of uses or disclosures, I will explain what I mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.
Cost:
For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care 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 health care provider’s own treatment, or health care operations. I reserve the right to use reasonable means to collect unpaid bills, including use of collection agencies and small claims court, the cost of which you may be asked to pay. Utilizing either of these methods will require me to disclose your name, the services provided, and the amount owed for the service. I may also disclose your protected health information for the treatment activities of any health care provider. This too, can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of 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/or full and complete information in order 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 healthcare providers, and referrals of a patient for health care from one healthcare provider to another.
III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:
Psychotherapy Notes. I do keep “psychotherapy notes” as that term is defined in 45 CFR § 164.501, and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:
a. For my use in treating you.
b. For my 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 my use in defending myself 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 pertaining to the originator of the psychotherapy notes.
g. Required by a coroner who is performing duties authorized by law.
h. Required to help avert a serious threat to the health and safety of others.
Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes.
Sale of PHI. As a psychotherapist, I will not sell your PHI in the regular course of my business.
IV. CERTAIN USES AND DISCLOSURES DO NOT REQUIRE YOUR AUTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:
When disclosure is required by state or federal law, and 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 health oversight activities, including audits and investigations.
For judicial and administrative proceedings, including responding to a court or administrative order, 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 are performing 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.
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 my preference is to obtain Authorization from you, I may provide your PHI in order to comply with workers’ compensation laws.
Appointment reminders and health-related benefits or services. I may use and disclose your PHI to contact you to remind you that you have an appointment with me. I may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits that I offer.
V. CERTAIN USES AND DISCLOSURES REQUIRE YOU TO HAVE THE OPPORTUNITY TO OBJECT.
1. Disclosures to family, friends, or others. I may provide your PHI to a family member, friend, or another person that 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 emergency situations.
VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO 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 that 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, home or office phone) 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 that 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, or health care operations or 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 from your PHI, 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 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 of it.
EFFECTIVE DATE OF THIS NOTICE
Notice of Psychotherapy Practice Policies
PRACTICE POLICIES
SCOPE of PRACTICE:
Informed Consent for Psychotherapy:
The therapeutic relationship is unique in that it is a highly personal and at the same time, a contractual agreement. Given this, it is important for us to reach a clear understanding about how our relationship will work, and what each of us can expect. This consent will provide a clear framework for our work together. Feel free to discuss any of this with me. Please read and indicate that you have reviewed this information and agree to it by signing electronically or by hand at the end of this document.
By agreeing to engage in a therapeutic relationship you have taken a very positive step. The outcome of your treatment depends largely on your willingness to engage in this process, which may, at times, result in considerable discomfort. Exploring unpleasant events and becoming aware of feelings attached to those events can bring on strong feelings. I cannot promise that your behavior or circumstance will change. I can promise to support you and do my very best to understand you and repeating patterns, as well as to help you clarify what it is that you want for yourself.
I recognize you have choices for whom you engage to provide treatment and I am honored you have chosen to consider working with me. Feedback and honest communication between us is essential to assure we are addressing the issues you have identified. If for some reason a concern arises in the treatment context it is your responsibility to bring it up so that we may address as soon as possible.
Treatment outcomes vary depending on a person’s individuals needs and circumstances and their interest in applying skills and insights outside the therapy session.
Change is a collaborative process. If at any point in the treatment you feel that my therapeutic approach is not right for you, we will discuss a transition to another health provider or alternate therapeutic approach. If at any point in the treatment I feel your needs are beyond my clinical capabilities, we will discuss a transition to another provider. It is my ethical duty to provide my best clinical judgement regarding optimal treatment.
Confidentiality
The session content and all relevant materials to the client’s treatment will be held confidential unless the client requests in writing to have all or portions of such content released to a specifically named person/persons. Limitations of such client held privilege of confidentiality exist and are itemized below:
If a client threatens or attempts to commit suicide or otherwise conducts him/her self in a manner in which there is a substantial risk of incurring serious bodily harm.
If a client threatens grave bodily harm or death to another person.
If the therapist has a reasonable suspicion that a client or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children under the age of 18 years.
Suspicions as stated above in the case of an elderly person who may be subjected to these abuses.
Suspected neglect of the parties named in items #3 and # 4.
If a court of law issues a legitimate subpoena for information stated on the subpoena.
If a client is in therapy or being treated by order of a court of law, or if information is obtained for the purpose of rendering an expert’s report to an attorney.
Occasionally I may need to consult with other professionals in their areas of expertise in order to provide the best treatment for you. Information about you may be shared in this context without using your name.
If we see each other accidentally outside of the therapy office, I will not acknowledge you first. Your right to privacy and confidentiality is of the utmost importance to me, and I do not wish to jeopardize your privacy. However, if you acknowledge me first, I will be more than happy to speak briefly with you but feel it appropriate not to engage in any lengthy discussions in public or outside of the therapy office.
Please be advised, that I am not trained in, nor do I offer any type of parental fitness assessments, custody evaluations or anything related to divorce or separation. I do not have the credentials to offer an opinion in these areas and will testify to this if brought to court.
Should you be involved in any type of personal or professional litigation it is agreed upon that Jennifer DeSouza, LICSW, CGP will not be requested by you or any other professional acting upon your behalf, and that I will not be requested to attend or testify in any type of legal proceeding. This is to protect the sensitive nature of our work together, topics discussed and notated within the context of the therapy. Should these requests be made despite the possibility of the disclosure of sensitive and personal information and of potential harm to the therapeutic relationship there will be an hourly rate of $200.00 per hour charged to you
SCHEDULING & CANCELLATION POLICY:
Unless we have decided to have a standing appointment, bookings take place on a first come, first serve basis. If you have reached out to book an appointment via email or text and available times are offered, I am unable to hold the unconfirmed time slots for more than 8 hours. If you need more time to confirm an appointment, please feel free to let me know and we can arrange that. Otherwise, the open appointment times may not be available after 8 hours. I do require a 24-hour notice for any reschedules and cancellations. Please email, text or call in the event you need to reschedule your appointment. Thank you for your understanding.
APPOINTMENTS & FINANCIAL POLICIES:
My session are 53 minutes in length. If you are not using insurance or are seeking reimbursement through a Health Savings Plan payment is due at the time of each session. I keep a debit, credit or Health Savings Card on file and automatically charge the fee (co-pay/co-insurance/and unmet deductible) at the time of each session. Adjustment in fees or deferred payment schedules can be negotiated in cases of financial hardship.
If you accrue a balance of $175 or greater, or if your bill remains unpaid for more than 60 days, we may need to pause treatment. In these cases, we may negotiate a payment plan which will need to be signed prior to resuming treatment.
I reserve the right to use reasonable means to collect unpaid bills including use of collection agencies and small claims court, the cost of which you may be asked to pay. Utilizing either of these methods will require me to disclose your name, the services provided, and the amount owed for the service.
SESSION COST: If you are using insurance and I am in network with your plan I will charge the contracted rate set by the insurance company. The initial intake is typically (60-90) minutes.
The initial session is $220.00 and my regular fee for on-going treatment is $175 for 53 minutes unless we agree upon another rate. For those not using insurance I will provide a Good Faith Estimate within 3 business days of our 1st appointment.
INSURANCE:
I do not accept insurance. If you are hoping to use out-of-network benefits it is very important that you check with your insurance company for their reimbursement policies and practices. Most PPO, Preferred Provider Plans, offer reimbursement upon submission of a paid reciept. Please know that even for reimbursement most insurance companies require mental health professionals to provide them with a clinical diagnosis from the American Psychiatric Association’s Diagnostic and Statistical Manual and that in some cases they may also request information including treatment plans, progress notes and/or care summaries. There is an inherent level of risk involved when this type of information is released, and I do not have control over what happens to the information if it is released to insurance companies.
NOTES & RECORDS:
As a licensed mental health provider I am required to keep notes and records regarding your treatment. These records will be stored within my encrypted electronic health record or in an encrypted HIPPA compliant device or cloud for a minimum of six years following treatment. You are entitled to a copy of your record. Should you choose to request a summary or your full record it is encouraged to review it with me to to provide the opportunity to ask questions and reduce the possibility of misinterpretation.
CANCELLATION POLICY
Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the cost of the cancelled session if cancellation is LESS THAN 24 HOURS IN ADVANCE. This is necessary because a time commitment is made to you and is held exclusively for you.
TELEPHONE ACCESSIBILITY
I can be reached at 617-575-9438 or at jenniferdesouzalicsw@protonmail.com. As I do not answer the telephone during sessions, I encourage you to leave a confidential voicemail at this number. I will attempt to return your call within 24 hours. If an emergency situation arises, please call 911 or go to the nearest hospital emergency room.
ELECTRONIC COMMUNICATION
You may use my email address (jenniferdesouzalicsw@protonmail.com) for scheduling and administrative functions. This is an encrypted email address. I do not perform therapy over email or text. Please do not use electronic methods of communication to discuss therapeutic content and/or request assistance for emergencies. For emergency situations, call 911 or go to the nearest hospital emergency room.
SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
Please be advised that social media platforms may suggest “connections” with me or others who visit my office. I have no control over this and suggest you review the privacy settings available to you to minimize intrusions to your privacy and confidentiality.
TERMINATION
The ending of therapy is referred to as “termination”. Ending relationships can be difficult. Therefore, it is important for us to have a thoughtful ending process to achieve therapeutic closure. The appropriate length of the termination process depends on the length and intensity of our work together. When it is time to end our therapy relationship, I would ask that we discuss it together during our session so we can process the feelings and create a plan for the future. You are free to terminate therapy at any time, and I am happy to provide you with a list of qualified psychotherapists for your next therapy.
Please note that if you do not schedule an appointment for four consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider our professional therapy relationship discontinued.