HIPAA Policy

Alicia M. Sisk, Phd
451 West End Ave. 1D
New York, NY 10024
646-924-09384p

Consultation and Psychotherapy Services Agreement

Please read the following sections regarding important guidelines for the provision of consultation and psychotherapy services in this practice. In order for our work to be most productive and effective, it is important that you have a clear understanding of your rights and responsibilities as a patient, as well what you can expect in terms of the structure of sessions, confidentiality, clinical records, scheduling, and payment.

I. Intake/Consultation

It is helpful to view the first 1-3 sessions as part of an initial consultation, during which we will determine together whether further working together would be beneficial. This is an opportunity for me to gather information and clarify the presenting concerns, and also a chance for you to ask any questions regarding my professional background, training, and credentials.

II. Psychotherapy

The psychotherapy process is collaborative and interactive, and I endeavor to create an environment of safety and security to address presenting concerns. We will discuss the frequency of sessions with a focus on determining the plan that is most helpful for resolving these concerns. Sessions are typically 45 minutes in length and take place in person.

III. Patient Rights

The Health Insurance Portability and Accountability Act (HIPAA) is a new federal law that provides privacy protection and patient rights with regard to the use and disclosure of your clinical records, also called Protected Health Information (PHI), used for the purpose of treatment, payment, and health care operations.

Please carefully review the Confidentiality section below. You will be asked to provide your signature to acknowledge your understanding of your rights under the privacy policy. Please feel free to raise with me any questions you have about these rights.

IV. Confidentiality

Confidentiality is a keystone of our work together, ensuring that you can address your concerns with the assurance that the information addressed in session is protected. In general, the law strictly protects the confidentiality of all communications between a patient and a psychotherapist.

With the exceptions noted below, I will release information about your treatment to others only if you sign a written consent. There are situations that require only that you provide written, advance consent, and your signature on this agreement provides consent for the following:

  • At times, it can be productive to consult with other health and mental health professionals, without revealing any identifying information about you. Other professionals are also legally bound to keep this information confidential.

  • Disclosures required by health insurers or to collect fees, as noted elsewhere in this agreement.

  • If a patient threatens to harm him/herself, I may be obligated to seek hospitalization for him/her, and/or to contact family members or others who can help provide protection.

There are some situations in which I am legally obligated to take actions that I believe are necessary to attempt to protect others from harm, and I may have to reveal some information about a patient’s treatment:

  • If I receive information in my professional capacity that gives me reasonable cause to suspect abuse or neglect of a child, the law requires that I report this to the appropriate governmental agency, usually the statewide central register of child abuse and maltreatment, or the local child protective services office. Once such a report is filed, I may be required to provide additional information.

  • If a patient communicates an immediate threat of serious physical harm to an identifiable victim, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

These situations are rare in my practice. If any such situation arises, I will make every effort to fully discuss it with you before taking any action, and I will limit my disclosure to what I deem necessary.

V. Clinical Records

As required by law, I maintain clinical records of our sessions containing Protected Health Information (PHI). All records are kept secure in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

VI. Scheduling

Your scheduled appointment time is reserved for you, and due to the difficulty of scheduling during open appointment times on short notice, I require a 24-hour notification if you cancel an appointment. If appointments are cancelled within 24 hours or missed, you will be charged for the appointment. Please bear in mind that most insurance companies do not reimburse for cancelled or missed appointments.

VII. Insurance reimbursement

For all insurances, I will provide the needed paperwork/statements for you to submit to insurance. I will collect the full fee directly from you, and the insurance company will reimburse you for any covered expenses.

VIII. Payment

Unless we make other arrangements, payment is due at the time of service, If at any point during the treatment, you anticipate difficulty with payment on the agreed upon schedule, please raise this as soon as possible so that we can develop a plan in response to the change.

IX. Informed Consent

Your signature below indicates that you have read this agreement and agree to its terms.

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