Client Information Formdavidindest.com/David_Indest,_PsyD,_Psychologist... · David Indest, PsyD...

David Indest, PsyD tel: 503-866-1966 4039 N Mississippi Ave, Ste 309, Portland OR 97227

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. of 3

Client Information Form

Today’s date:

Identification

Your Name: Date of Birth: Age:

Preferred Name or Nicknames: Social Security #:

Ethnic Identity: Gender Identity:

Sexual Identity:

Mailing Address: Apt:

City: State: Zip:

Home Address (if different):

Home Phone: Mobile Phone:

Please indicate any restrictions on calls:

Emergency Contact Information

Name: Phone:

Address:

Relationship to you:

Your Current Employer

Employer: Work phone:

Address:

City: State: Zip:

Occupation: Length of time with this employer:

Please indicate any restrictions on calls:

How did you hear about me?

Name/Source: Relationship:

How did this person recommend I might be of help to you?

Chief Concern

Please describe the main difficulty that has brought you to see me:

Your Medical Care (From whom or where do you get your medical care?)

Clinic Name: Phone:

Doctor’s Name:

Address:

If you enter treatment with me for psychological problems, may I tell your medical doctor so that he or she can be fully informed, and we can coordinate your treatment? ! Yes ! No

Please list any medical or physical conditions that affect you:


How might my services help you manage these conditions:

Present Relationships

How do you feel about your intimate relationships?

List of Symptoms

Please circle any of the following that are bothering you: marriage/partners headaches depression stress sexual abuse

sexual behavior chronic pain no interests anxiety abused as a child relationships extreme fatigue tiredness insomnia crime victim

sexual identity stomach trouble suicidal thoughts nightmares bigotry divorce/break-up bowel trouble sadness nervousness oppression

interpersonal conflict appetite energy (hi or low) panic attacks life meaning

being a parent eating problems ambition agoraphobia spiritual concerns children overweight unhappiness fears work

friends health problems grief/ loss phobias career choices sexual performance memory separation worry school work

self-control concentration loneliness perfectionism finances risk taking head injury self-esteem obsessive thinking legal matters

drug use making decisions inferiority feelings compulsions short temper

alcohol use thinking shyness/ confidence painful thoughts anger addiction paranoia guilt homicidal

Indicate how the issue(s) for which you are seeking treatment affect the following areas of your life

No effect

Little effect

Some effect

Much effect

Significant effect

Not applicable

Intimate relationships 1 2 3 4 5 N/A

Family 1 2 3 4 5 N/A

Friendships 1 2 3 4 5 N/A

Job/ School performance 1 2 3 4 5 N/A

Financial situation 1 2 3 4 5 N/A

Physical health 1 2 3 4 5 N/A

Anxiety level/ Nerves 1 2 3 4 5 N/A

Mood 1 2 3 4 5 N/A

Eating habits 1 2 3 4 5 N/A

Sleeping habits 1 2 3 4 5 N/A

Sex life 1 2 3 4 5 N/A

Alcohol/ Drug usage 1 2 3 4 5 N/A

Concentration 1 2 3 4 5 N/A

Temper 1 2 3 4 5 N/A


Past Psychological/Psychiatric Treatment

Have you ever received psychological, psychiatric, drug, or alcohol treatment, or counseling services? Please include both inpatient and outpatient treatment. ! Yes ! No

If yes, please indicate:

When From Whom For What Results

Have you ever taken medications for psychiatric or emotional issues? ! Yes ! No

If yes, please indicate:

When From Whom Medication For What Results

Other

Is there anything else that is important for me to know about and that you have not written about on any of these forms? Please tell me here; use more paper if needed.

Information for Clients

David Indest, PsyD Clinical Psychologist

•

4039 N Mississippi Ave, Ste 309 Portland OR 97227

•

phone: 503-866-1966


Welcome to my practice. I appreciate you giving me the opportunity to work with you. This document answers some questions clients often ask about any therapy practice. It is important to me that you know how we will work together. I believe our work will be most helpful to you when you have a clear idea of what we are trying to do. After you read this brochure we can discuss, in person, how these issues apply to your own situation. This brochure is yours to keep and refer to later.

About Psychotherapy During the first few sessions, I will discuss with you my approach to psychotherapy, as well as risks, benefits, and other important aspects. I may also recommend psychological testing or other forms of assessment. After the initial evaluation phase, which typically takes 2 to 3 sessions, we will discuss a treatment plan. I view therapy as a partnership between us. You define the goals and problem areas for our work; I use some special knowledge to help you make the changes you want to make.

Scheduling Sessions My practice operates by appointment only. Each session is typically scheduled for 45 minutes; however, there are times where I may schedule a shorter or longer session, depending on our goals and your progress. If, after the initial evaluation, we agree to begin therapy, we will decide on a frequency of meetings (usually once a week), and I will reserve a specific time every week just for you. If you are unable to keep an appointment, I request that you give me 24 hours notice. Because I am rarely able to fill a time slot with less than a week’s notice, I will bill you for appointments you do not cancel within 24 hours of the appointment time. Your insurance company will not pay for missed appointments, so you are solely responsible for paying for these missed appointments. If you have the type of schedule that makes consistent weekly appointments impossible, we may be able to work out a schedule that meets both of our needs. If you cancel or miss too many appointments, you may lose your regular appointment time and have to schedule our meetings based on my availability each week. If I judge that excessive missed appointments are interfering with our goals, I may terminate therapy.

The Benefits and Risks of Therapy As with any treatment, there are some risks as well as many benefits. Some risks of psychotherapy include a temporary increase in unpleasant feelings such as sadness, guilt, anxiety, anger, frustration, loneliness, helplessness, or other feelings; recall of unpleasant memories; unveiling of family secrets; disruption of relationships, which sometimes may lead to divorce; or temporary worsening of your problem. In addition, some people in your community may mistakenly view anyone in therapy as weak, or perhaps disturbed. Most of these risks are to be expected when people are making important changes in their lives. Finally, even with our best efforts, there is a risk that therapy may not work out well for you. While you consider these risks, you should know also that many people find therapy very beneficial, and research into whether therapy works shows that it generally works very well. People who are depressed may find their mood lifting. Others may no longer feel afraid, angry, or anxious. In therapy, people have a chance to take new points of view, to express their feelings and thoughts, to practice new skills, and to develop new strategies. Clients’ relationships and coping skills may improve greatly. They may get more satisfaction out of social and family relationships. Their personal goals and values may become clearer. They may grow in many directions—as individuals, in their close relationships, in their work or schooling, and in the ability to enjoy their lives.


Other Services In addition to psychotherapy, I also do psychological assessments. Psychological assessments are different from psychotherapy in that we will have a few appointments together (usually 2 to 3) focused on a specific referral question. At the end of our time together, I will write a report and send it to the provider who requested the assessment. During our time together I will ask you many questions, some of which may not seem like they are related to the issue being assessed. I may also ask you to complete one or more questionnaires or give you some tests, depending on the referral question. All of the same rules of confidentiality described in the About Confidentiality section still apply.

What to Expect from Our Relationship As a professional, I will use my best knowledge and skills to help you. This includes following the standards of the American Psychological Association (APA). In your best interests, the APA puts limits on the relationship between a therapist and a client, and I will abide by these. Let me explain these limits, so you will not think they are personal responses to you. First, I am licensed and trained to practice psychology — not law, medicine, finance, or any other profession. I am not able to give you good advice from these other professional viewpoints. Second, state laws and the rules of the APA require me to keep what you tell me confidential (that is, private). You can trust me not to tell anyone else what you tell me, except in certain limited situations. I explain what those are in the About Confidentiality section of this brochure. Third, in your best interest, and following the APA’s standards, I can only be your therapist. I cannot have any other role in your life. I cannot, now or ever, be a close friend or socialize with any of my clients. I cannot be a therapist to someone who is already a friend. I can never have a sexual or romantic relationship with any client during, or after, the course of therapy. I cannot have a business relationship with any of my clients, other than the therapy relationship. These limits are necessary to maintain the therapeutic relationship, which allows me to focus on you and your needs. This is a very different kind of relationship for most people: in most relationships, both people expect to have their needs met by the other. However, in a therapeutic relationship, the therapist does not attempt to meet his/her needs, focusing instead on the client’s best interest at all times. Even though you might invite me, I will not attend your family gatherings, such as parties or weddings. As your therapist, I will not celebrate holidays or give you gifts; I may not notice or recall your birthday; and may not receive any of your gifts eagerly.

About Confidentiality In general, state and federal law protects the privacy of all communications between a patient and a psychologist, and in most cases I can only provide information to others if you sign a written consent. There are a few cases in which confidentiality is not protected: 1. If you were sent to me by a court or an employer for evaluation or treatment, the court or employer expects a report from me. If this is your situation, please talk with me before you tell me anything you do not want the court or your employer to know. You have a right to tell me only what you are comfortable telling. 2. If you are involved in any type of legal proceeding and you tell the court that you are seeing me, I may be ordered to show the court my records. Please consult your lawyer about these issues.


3. If you make a serious threat to harm yourself or another person, I am obligated to try to protect you or that other person: the law also requires me to do so. This usually means telling others about the threat. I cannot promise never to tell others about serious threats you make. 4. If I believe a child, dependent, or elderly person has been or will be abused or neglected, I may report this to the authorities to protect that person who is unable to protect him- or herself. If I am serving as your psychologist, I may also use or disclose protected health information (PHI) for purposes of treatment, payment, and healthcare operations. The rules about the use and disclosure of your personal information are governed by the Health Insurance Portability and Accountability Act (HIPAA) and Oregon state law. Please read the Notice of Privacy Practices for details about use and disclosure of PHI. There are two other situations in which I might talk about part of your case with another therapist. First, when I am away from the office for a few days, I have a trusted fellow therapist “cover” for me. This therapist will be available to you in emergencies. Therefore, he or she needs to know about you. Of course, this therapist is bound by the same laws and rules as I am to protect your confidentiality. Second, I sometimes consult other therapists or other professionals about my clients. This helps me in giving high-quality treatment. These other therapists are also required to keep your information private. Your name will never be given to them, and they will be told only as much as they need to know to understand your situation. If I must discontinue our relationship because of illness, disability, or other presently unforeseen circumstances, I ask you to agree to my transferring your records to another therapist who will assure their confidentiality, preservation, and appropriate access. If we do family, partner, or couple therapy (where there is more than one client), and you want to have my records of this therapy sent to anyone, all of the adults present will have to sign a release. When you sign a health insurance contract, you automatically agree to release your protected information to the insurer. By requesting to use your health insurance to pay for my services, you are automatically authorizing a release of sufficient information to verify your insurance claim. As part of cost control efforts, an insurance company will sometimes ask for more information on symptoms, diagnoses, and my treatment methods. It will become part of your permanent medical record. I will let you know if this should occur and what the company has asked for. Please understand that I have no control over how these records are handled at the insurance company. My policy is to provide only as much information as the insurance company will need to pay your benefits.

Fees, Payments, and Billing My current fees are as follows. You will be given at least 30 days’ advance notice if my fees should change. • Initial 90-minute intake & assessment session: $275. • Individual therapy 20-minute session: $100. • Individual therapy 45-minute session: $150. • Individual therapy 75-minute session: $225. • Couples/Triad therapy 45-minute session: $225. • Group therapy session: $50. • Telephone consultations: $31.25 per 15 minutes ($125 per hour). No charge for administrative calls. • Psychological testing services: $250 per hour. Psychological testing fees include the time spent with you, the

time needed for scoring and studying the test results, and the time needed to write a report on the findings. • Other services: $250 per hour. Other services include, but are not limited to, consultation with other healthcare

providers, consultations with attorneys, responding to a subpoena, providing courtroom testimony, etc.


Please pay for each session at the time of service. Other payment or fee arrangements must be worked out before the end of our first meeting. Because I expect all payment at the time of our meetings, I usually do not send bills. However, if we have agreed that I will bill you, I ask that the bill be paid within 10 days of when you get it. If you think you may have trouble paying your bills on time, please discuss this with me. I will also raise the matter with you so we can arrive at a solution. If your unpaid balance reaches $300, I will notify you by mail. If it then remains unpaid, I must stop therapy with you.

If You Have Health Insurance Coverage Because I am a licensed psychologist, many health insurance plans will help you pay for therapy and other services I offer. However, only your insurance company can tell you what your plan covers. I am a Preferred Provider only on a limited number of plans. If I am not a Preferred Provider on your plan, you will have to submit my bills to your plan for reimbursement; however, there is no guarantee your insurance will reimburse you for my services in these circumstances. Please remember that your insurance contract is between you and the insurance company. Insurance companies often do not pay for telephone calls, court testimony, coordinating care with another provider, writing letters on your behalf, paperwork, or missed appointments. You are responsible for paying the fees that we have agreed upon — not the insurance company. If you choose to use your insurance to pay for my services, you should be aware that your contract with your insurance company may require that I provide it with information relevant to services I provide for you. Most Oregon insurance policies come with a state law requirement that states that by accepting policy benefits, you are deemed to have consented to examination of your Clinical Record for purposes of utilization review, quality assurance, and peer review by the insurance. If this is the case, I may provide clinical information to your insurer for such purposes. Sometimes insurance companies will require that I provide additional information about your symptoms, diagnosis, treatment plan, and progress. You should know that there are no restrictions on the amount or type of information they can request or require. I will make every effort to release only the minimal amount of information necessary for the purpose requested. If you wish, I will discuss with you the content of any reports I supply. Although your insurance company should treat this information as confidential, I cannot be responsible for the insurance company’s use of any information that I provide to them at their request and with your authorization. By signing this agreement, you agree that I can provide requested information to your insurance company.

If You Need to Contact Me I cannot promise that I will be available at all times, and I do not provide 24-hour on-call services. I do not take phone calls when I am with a client. You can always leave a message on my confidential voicemail, and I will return your call as soon as I can. Generally, I will return messages daily except on weekends, holidays, and vacations. Please know that when you or I use a cell phone it may not be secure. Similarly, e-mail is never a secure form of communication, so I do not use it to communicate with clients about confidential matters. In the interest of preserving your confidentiality, I must ignore such e-mails. If you have an emergency or feel that you cannot wait for me to return your call, please call the Multnomah County Crisis line at (503)-988-4888, 911, or your primary care physician. You may also go to the nearest hospital Emergency Room and ask for the psychiatrist on call. The Emergency Room physician should be given a release to speak with me.


Other Points If you ever become involved in a legal dispute, I want you to understand and agree that I will not provide evaluations or expert testimony in court. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on 3 reasons: (1) My statements will be seen as biased in your favor because we have a therapy relationship; (2) Most legal proceedings are adversarial and sensitive matters you reveal in therapy could be used to harm you; and (3) The testimony might affect our therapeutic relationship, and I must put this relationship first. If, as part of our therapy, you create and provide to me records, notes, artworks, or any other documents or materials, I will return the originals to you at your written request but will retain copies. I am a sole practitioner. Although I share office space with other practitioners, we are not a group and we do not function as a group; I am not liable for the actions of any other provider in the building, and they are not liable for any of my actions.

Statement of Principles and Complaint Procedures It is my intention to fully abide by all the rules of the American Psychological Association (APA) and by those of my state license. Problems can arise in our relationship, just as in any other relationship. If you are not satisfied with any area of our work, please raise your concerns with me at once. Our work together will be slower and harder if you do not voice your concerns with me. I will make every effort to hear any complaints you have and to seek solutions to them. If you feel that I, or any other therapist, has treated you unfairly or has even broken a professional rule, please tell me. You can also contact the state or local psychological association and speak to the chairperson of the ethics committee. He or she can help clarify your concerns or tell you how to file a complaint. You may also contact the State Board of Psychologist Examiners, the organization that licenses those of us in the independent practice of psychology. Social Justice is one of the many important values I pursue in my work. In my practice as a therapist, I do not discriminate against clients because of any of these factors: age, sex, relational/marital/family status, race, color, religious beliefs, ethnic origin, place of residence, veteran status, physical disability, health status, sexual orientation, or criminal record unrelated to present dangerousness. This is a personal commitment, as well as being required by federal, state, and local laws and regulations. I will always take steps to advance and support the values of equal opportunity, human dignity, social justice, and racial/ethnic/cultural diversity. If you believe you have been discriminated against, please bring this matter to my attention immediately.


Our Agreement I, the client (or his or her parent or guardian), understand I have the right not to sign this form. My signature below indicates that I have read and discussed this agreement; it does not indicate that I am waiving any of my rights. I understand I can choose to discuss my concerns with you, the therapist, before I start (or the client starts) formal therapy or assessment. I also understand that any of the points mentioned above can be discussed and may be open to change. If at any time during the treatment I have questions about any of the subjects discussed in this brochure, I can talk with you about them, and you will do your best to answer them. I understand that therapy works only when I participate actively and follow my therapist’s recommendations; therefore, I will make every effort to participate fully and keep scheduled appointments, for my own benefit and out of respect for myself, my therapist, and the therapeutic process. I understand that after therapy begins I have the right to withdraw my consent to therapy at any time, for any reason. However, I will make every effort to discuss my concerns about my progress with you before ending therapy. I understand that no specific promises have been made to me by this therapist about the results of treatment, the effectiveness of the procedures used by this therapist, or the number of sessions necessary for therapy to be effective. I understand that any psychological assessment report written as part of an assessment at the request of another provider/agency will be sent to the provider/agency that requested the report. I have read, or have had read to me, the issues and points in this brochure and in the Notice of Privacy Practices brochure. I have discussed those points I did not understand and have had my questions, if any, fully answered. I agree to act according to the points covered in this brochure. I hereby agree to enter into therapy with this therapist (or to have the client enter therapy), and to cooperate fully and to the best of my ability, as shown by my signature here. ______________________________________________ ____________ Signature of client (or person acting for client) Date ______________________________________________ Printed name ______________________________________________ Relationship to client: I, the therapist, have met with this client (and/or his or her parent or guardian) for a suitable period of time and have informed him or her of the issues and points raised in this brochure. I have responded to all of his or her questions. I believe this person fully understands the issues, and I find no reason to believe this person is not fully competent to give informed consent to treatment. I agree to enter into therapy with the client, as shown by my signature here. ______________________________________________ ____________ Signature of therapist Date ___ Copy accepted by client ___Copy kept by therapist

Agreement to Pay for Professional Services

I request that David Indest, PsyD, provide psychological services to me (or to ______________________, who is my

___________________________) and I agree to pay for Dr. Indest’s services at the time rendered and according to

the attached Fee Schedule.

Furthermore, I agree to all of the following:

• To meet with Dr. Indest at our regularly scheduled appointments.

• To meet with Dr. Indest at least once before stopping therapy.

• To pay for services provided to me (or this client) up until the time I end the relationship.

• To pay for no-shows or appointments canceled with less than 24 hours notice.

• To be responsible for the charges for services provided by Dr. Indest to me (or this client). Although other

persons or insurance companies may make payments to me or on my (or this client’s) account, I am solely

responsible for all charges.

• To continue this financial relationship with Dr. Indest as long as he provides services or until I inform him, in person or by certified mail, that I wish to end it.

I have also read Dr. Indest’s Information for Clients brochure and agree to act according to everything stated there, as

shown by my signature below.

__________________________________________ ________________________ Signature of client (or person acting for client) Date

___________________________________________

Printed Name

I, David Indest, PsyD, have discussed the issues above with the client (and/or the person acting for the client). My observations of the person’s behavior and responses give me no reason to believe that this person is not fully

competent to give informed and willing consent.

__________________________________________ ________________________

Signature of David Indest, PsyD Date

! Copy accepted by client ! Copy kept by therapist


Fee Schedule for Professional Services

• Initial 90-minute intake & assessment session: $275. • Individual therapy 20-minute session: $100. • Individual therapy 45-minute session: $150. • Individual therapy 75-minute session: $225. • Couples/Triad therapy 45-minute session: $225. • Group therapy session: $50 per person. • Telephone consultations: $31.25 per 15 minutes ($125 per hour). No charge for administrative

calls. • Psychological testing services: $250 per hour. Psychological testing fees include the time

spent with you, the time needed for scoring and studying the test results, and the time needed to write a report on the findings.

• Other services: $250 per hour. Other services include, but are not limited to, consultation with other healthcare providers, consultations with attorneys, responding to a subpoena, providing courtroom testimony, etc.


Effective Date: October 1, 2005

David Indest, PsyD 4039 N Mississippi Ave, Ste 309

Portland OR 97227

NOTICE OF PRIVACY PRACTICES The privacy of your health information is important to me. I will maintain the privacy of your health information and I will not disclosure information to others unless you tell me to do so, or unless the law authorizes or requires me to do so. A new federal law commonly known as HIPAA (Health Insurance Portability and Accountability Act) requires that I take additional steps to keep you informed about how I may use information that is gathered in order to provide mental health services to you. As part of this process, I am required to provide you with the attached Notice of Privacy Practices and to request that you sign the attached as written acknowledgment that you have received a copy of the Notice. The Notice describes how I may use and disclose your protected health information to carry out treatment, payment, or health-care operations and for other purposes that are permitted or required by law. This Notice also describes your rights regarding health information I maintain about you and a brief description of how you may exercise these rights. Please let me know if you have any questions or concerns about this Notice.


David Indest, PsyD 4039 N Mississippi Ave, Ste 309

Portland OR 97227

NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION MAY

BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

If you have any questions about this Notice, please contact David Indest, PsyD, at 503-866-1966, 4039 N Mississippi Ave, Ste 309, Portland OR 97227. YOUR HEALTH INFORMATION This Notice applies to the records and information I have about you, your health, your health status, and the health care and services you received from me. Your health Information may include information created in received by me, maybe in the form of written or electronic records were spoken words, and may include information about your health history, health status, symptoms, examinations, test results, diagnoses, treatment, procedures, prescriptions, and similar types of health-related information. This Notice will tell you the ways in which we may use and disclose health information about you and describe your rights and our obligations regarding the use and disclosure of that information.

USES AND DISCLOSURES FOR TREATMENT, PAYMENT, AND HEALTH-CARE OPERATIONS

I may use or disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. To clarify these terms, here are some definitions: PHI refers to information in your health record that could identify you. Treatment, payment, and health-care operations

• Treatment is when I provide, coordinate, or manage your health care and other services related to your health care. For example, if I consult another health-care provider, such as your family physician or another psychologist, this would require disclosure of some of your health information for treatment purpose.

• Payment is when I obtain reimbursement for your health care. For example, I may need to disclose some of your PHI to your health insurer in order to obtain reimbursement for your health care or to determine eligibility for coverage.


Making requests related to your PHI DENIAL OF REQUESTS TO INSPECT AND COPY YOUR HEALTH INFORMATION I may deny your request to inspect and/or copy your health information under certain circumstances. If you are denied copies of or access to health information that I keep about you, you may ask that your denial be reviewed. If the law gives you a right to have my denial reviewed, I will select a licensed health care professional to review the request and my denial. I will comply with the outcome of the review. TO REQUEST AN AMENDMENT TO YOUR HEALTH INFORMATION AND RECORD You have the right to request an amendment as long as I keep the information. To request an amendment, complete and submit a CLINICAL RECORD AMENDMENT/ CORRECTION FORM to David Indest, PsyD. I may deny your request for an amendment if your request is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask me to amend information that (1) I did not create, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the health information that I keep; (3) you would not be permitted to inspect and copy the information; or (4) is accurate and complete. TO REQUEST RESTRICTIONS OF THE DISCLOSURE OF YOUR HEALTH INFORMATION To request restrictions on the health information I use or disclose about you for treatment, payment, or health-care operations, you must complete and submit the REQUEST FOR RESTRICTION OF USE OR DISCLOSURE OF CLINICAL INFORMATION to David Indest, PsyD. TO REQUEST AN ACCOUNTING OF DISCLOSURES To obtain a list of the disclosures I made for information about you for purposes of the treatment, payment, health-care operations, and a limited number of other special circumstances, you must submit your request in writing to David Indest, PsyD. It must state a time period. The time period may not be longer than six years and may not include dates before October 1, 2005. Your request should indicate in what form you want the list (for example, on paper or electronically). The first list you request within a 12-month period will be free. For additional lists, I will charge you for the cost of providing the list. I will notify you of the costs involved, and you may choose to drop or modify your request before any costs are incurred. TO REQUEST A CHANGE IN THE MANNER OF CONFIDENTIAL COMMUNICATIONS To request a change in the manner in which I provide confidential communications, you may complete and submit the REQUEST FOR RESTRICTION OF USE OR DISCLOSURE OF CLINICAL INFORMATION FORM to David Indest, PsyD. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Right to Request Restrictions. You have the right to request restrictions on


certain uses and disclosures of PHI regarding yourself. However, I am not required to agree to a restriction or request.

• Right to an Accounting of Disclosures. You have the right to receive an accounting of disclosures of PHI. Upon your request, I will discuss with you the details of the accounting process.

• Right to Request the Manner of Confidential Communications. You have the right to request and receive communications of PHI by alternative means and at alternative locations. For example, if you do not want a family member to know you are seeing me, upon your request, I can send your bills to another address.

• Right to Inspect and Copy. You have the right to inspect and copy your health information, such as progress notes and billing records, that I keep and use to make decisions about your care. I may deny your access to PHI under certain circumstances. (For example, if I believe it may be harmful to you.) In some cases you may have this decision reviewed. Upon your request, I will discuss with you the details of the decision review process.

• Right to Amend. You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your requests. Upon your request, I will discuss with you the details of the amendment process.

• Right to a Paper Copy. You have the right to obtain paper copy of this Notice from me upon request, even if you have agreed to receive it electronically. To obtain a copy of this Notice, contact David Indest, PsyD at 503-866-1966.

CHANGES TO THIS NOTICE I am required by law to maintain the privacy of PHI and provide you with this Notice of my legal duties and privacy practices with respect to PHI. I reserve the right to change this Notice and to make the revised or changed Notice effective for clinical information I already have about you, as well as information I receive in the future. I will post a summary of the current Notice in the waiting area with its effective date in the bottom right hand corner. You are entitled to a copy of the Notice currently in effect. COMPLAINTS If you’re concerned that I have violated your privacy rights or you disagree with a decision I made about access to your records, please contact me about the complaint. You may also send a written complaint to the Secretary of the Department of Health and Human Services at the following address: Region X, Office for Civil Rights US Department Of Health And Human Services 2201 Sixth Ave, Suite 900 Seattle, WA 98121-1831 You will not be penalized for filing a complaint.

• Workers Compensation. I may release health information about you for workers compensation or similar programs to the extent necessary to comply with laws related to workers compensation or other programs.

• Public Health Risks. I may disclose health information about you for public health reasons; in order to prevent or control disease, injury or disability; or to report suspected abuse or neglect, non-accidental physical injuries, or reactions to medications.


• Health Oversight Activities. I may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance of civil rights laws.

• Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.

• Law Enforcement. I may release information if I am asked to do so by law enforcement officials in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

• Information Not Personally Identifiable. I may use or disclose health information about you in a way that does not personally identify you or reveal who you are.

• Family and Friends. I may disclose health information about you to your family members or friends if I obtain your verbal agreement to do so, or if I give you an opportunity to object to such disclosure and you did not raise an objection. I may also disclose health information to your family or friends if I can infer from the circumstances, based on my professional judgment that you would not object. I may assume you agree to my disclosure of your personal health information to your partner/spouse if you bring your partner/spouse with you into the room during treatment or while treatment is discussed.

In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), I may, using my best professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, I will disclose only health information relevant to the person’s involvement in your care.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION I will not use or disclose your health information for any purpose other than those identified in previous sections without your specific, written authorization. If you give me the authorization to use or disclose health information about you, you may revoke that authorization in writing at any time. If you revoke your authorization, I will no longer use or disclose information about you for the reasons covered by your authorization, but I cannot take back any uses or disclosures already made with your permission. In some instances, I may need specific, written authorization from you in order to disclose certain types of specially protected information such as HIV or substance abuse information. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION You have the following rights regarding health information I obtain about you:

• Health-care operations or 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 of administrative services, and case management and care coordination.

Use applies only to activities within my office such as sharing, employing, applying,


utilizing, examining, and analyzing information that identifies you. Disclosure applies to activities outside my office, such as releasing, transferring, or providing access to information about you to other parties. Please note: once information leaves this practice and becomes part of any data resource beyond my control, such as when I release your health information to your insurance company, I can no longer guarantee by whom and under what conditions it will be disclosed. HIPAA regulations permit your PHI to be used by third-party payers for the purposes they define as relevant to their payment and health-care operations. Please review the Privacy Practices Notices for your health insurers for information about how they use and disclose your PHI. USES AND DISCLOSURE REQUIRING AUTHORIZATION I may use or disclose PHI for purposes outside of treatment, payment, or health-care operations when your appropriate authorization is obtained. An authorization is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment, or health-care operations, I will obtain authorization from you before releasing information. I will also need to obtain authorization before releasing your Psychotherapy Notes. Psychotherapy Notes are notes I have made about our conversation during a private, group, joint, or family therapy/counseling session that I have kept separate from the rest of your medical record. These notes are given a greater degree of protection than PHI. You may revoke all such authorizations (of PHI or Psychotherapy Notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and the law provides the insurer the right to contest the claim under the policy. USES AND DISCLOSURES WITH NEITHER CONSENT NOR AUTHORIZATION I may use or disclose health information about you for the following purposes, subject to all applicable legal requirements and limitations:

• Serious Threat to Health or Safety. I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. If you communicate a serious threat of violence against another person or if you are in imminent risk of inflicting serious harm on yourself, I may disclose information in order to initiate hospitalization.

• Required by Law. I will disclose health information about you if I am required to do so by federal, state, or local law.


This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. Page 1 of 2

Client Insurance Form

Today’s date:

Identification

Client Name: Date of Birth: Age:

Client’s Phone: Social Security #:

Primary’s Name: Date of Birth: Age:

Primary’s Phone: Social Security #:

Mailing Address: Apt:

City: State: Zip:

Insurance Source: Expires:

Primary Insurance Information

Company: Phone:

Plan: Phone:

Member #: Group #:

Address:

I am IN / OUT of Network

Reimburse: Customary: Co-Pay:

Yearly Sessions: Sessions Used: Plan Year:

Deductible Met OOPocket Met

In Network

Out of Network

I authorize David Indest, PsyD to bill my insurance company for his services.

__________________________________________ ________________________

Signature of insured Date

__________________________________________ Printed Name

Notes:

This is a strictly confidential patient medical record. Redisclosure or transfer is expressly prohibited by law. Page 2 of 2

Secondary Insurance Information

Company: Phone:

Plan: Phone:

Member #: Group #:

Address:





In Network

Out of Network

Notes:

Tertiary Insurance Information

Company: Phone:

Plan: Phone:

Member #: Group #:

Address:





In Network

Out of Network

Notes:

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