I. MY PLEDGE REGARDING HEALTH INFORMATION AND REQUIREMENTS OF HIPPA:

The information that is shared in sessions is often sensitive information, and by law it is protected. I am committed to you and your privacy.  Records are an important and necessary part of the therapeutic process, and the following will help to explain the policies, my responsibiities, and your rights. By law I am required to:

- Make sure that your PHI and information that identifies you is kept private.
- Give you this notice of my legal duties and privacy practices with respect to health information.

- Keep you apprised of any changes that may occur.  These changes will be available through print or through the website up request.

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.

For Treatment Payment, or Health Care Operations: Federal privacy rules and regulations allow health care providers who have direct treatment relationship with the client to use or disclose the client's personal health information without the client's written authorization, to carry out the health care provider's own treatment, payment or health care operations. 

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 health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, I may disclose health information in response to a court or administrative order. I may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

III. CERTAIN USES AND DISCLOSURES REQUIRE YOUR AUTHORIZATION:

1. 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 defending myself in legal proceedings instituted by you.

c. For use by the Secretary of Health and Human Services to investigate my compliance with HIPAA.

d. Required by law and the use or disclosure is limited to the requirements of such law.

e. For the purpose of averting danger to any person.

2. Marketing Purposes. As a psychotherapist, I will not use or disclose your PHI for marketing purposes. 3. 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 AURTHORIZATION. Subject to certain limitations in the law, I can use and disclose your PHI without your Authorization for the following reasons:

Most importantly, if I believe you are a danger to yourself, another individual, or if there are signs that you are gravely disabled I will take whatever steps neccessary to keep you safe.  In addition:  

1. 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.

2. 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.

3. For health oversight activities, including audits and investigations.

4. For judicial and administrative proceedings, including responding to a court or administrative order, although my preference is to obtain an Authorization from you before doing so.

5. For law enforcement purposes, including reporting crimes occurring on my premises.

6. To coroners or medical examiners, when such individuals are performing duties authorized by law.

7. 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.

8. 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.

9. For workers' compensation purposes. Although my preference is to obtain an Authorization from you, I may provide your PHI in order to comply with workers' compensation laws.

10. 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. There may be instances where I believe it is in your best interest to share PHI with additional entities (family, caregiver, spouse or significant other, or employer.  As long as the information being share is not that of an emergent nature (see above) you have the ability to decide whether or not this happens by signing a release of information. 

2. You also have to right to decide to limit how much information is shared.  My usual policy to share the least amount of information needed in order to meet the need/goal of the disclosure.

VI. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PHI:

1. 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.

2. 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.

3. 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.

4. 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.

5. 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 an 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.

6. 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.

7. 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.

8. The right to be treated with dignity and respect.

9. The right to end therapy at any point in time.

Complaints
If you are concerned that your privacy rights have been violated, or you disagree with a decision made about access to your records, you may contact Megan Knueve, LCSW 317-344-9884. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY NOTICE

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By signing this document, you are acknowledging that you have received a copy of HIPPA Notice of Privacy Practices. 

Counseling Information and Consent for Treatment

CONFIDENTIALITY is absolutely respected in this office. There are, however, some limits to confidentiality.  I want you to know that I will not hesitate to break confidentiality if I am ever concerned that you are feeling like hurting yourself or someone else or if for some reason I do not feel safe letting you leave this office or being able to care for yourself.   If you need to leave a message for me outside of a session the client portal is confidential.  Additionally, in the event that we run into each other outside of counseling, it is my policy to not acknowledge you unless you initiate a "hello" first. This is to ensure your complete confidentiality and puts the decision in your hands.

FEES
Payment is due prior to or at the time of service unless other arrangements are made. Prior to the first appointment I will take down a credit card number which will only be charged if you fail to show up to your initial appointment or do not call within 24 hours of your appointment time.  Accepted payments are credit card, health savings accounts, personal check or cash. Checks are payable directly to Megan Knueve, LCSW.
Initial meeting: $150

Follow up sessions: $130 

Group sessions: $40

Missed appointment fee/late cancellation: Full fee

Returned check: $25

FMLA/Short Term Disability/paperwork: $25-100 (dependent on length and time to complete)

INSURANCE

You may choose to use your insurance to help pay for your sessions.  It is YOUR responsibility to make sure your provider is in network, and to take care of any prior authorizations that might need to be done.  Clients assume all financial responsibility for fees not paid by their insurance.  If I am not in network with your insurance I am happy to give you a receipt so that you can file it as out of network.

CANCELLATIONS and MISSED APPOINTMENTS
Appointments must be cancelled at least 24 hours in advance of the scheduled appointment time. Failure to provide 24-hour notice will result in a "Missed Appointment" charge. The fee for missing an appointment is as shown above.

SAFETY

If you are in a CRISIS situation that compromises your safety it is essential that you contact an emergency 24-hour help-line. St. Vincent's is one of the many hospitals offering a help line and their number is 317.338.4800. If you are feeling suicidal, or you question your safety, it is essential that you call the help-line immediately.

COMMUNICATION

Occasionally a client will need to contact the therapist with questions or concerns between sessions. The fee for occasional and brief (5 minutes or less) telephone/email contact between the therapist and client are included in the fees paid for routine office visits. If frequent or prolonged conversations are required (especially those of a therapeutic nature) a fee of $5 per minute will be charged.  I can be contact during normal business hours Monday-Thursday through text, phone, or portal message.  Due to the nature of private practice there may some times where it takes longer to get back to you.  I will do my best to get back to you as soon as I possibly can.  

OFFICE VISITS 

Sessions typically range from 45 to 55 minutes in length and every attempt will be made to start and end on time.  If you are more than 15 minutes late to your appointment it will be considered a missed session and applicable fees will apply.

Office visits can be subject to change due to inclement weather, sudden illness, or other reasons approved by Megan Knueve, LCSW. During these times appointments may be subjected to cancelation, rescheduling, or offered to be held over the phone/video conferencing. 

LEGAL ENGAGMENT 

I prefer not to engage in legal matters (custody or divorce), and recommend that you seek another therapeutic professional if you want to obtain information to use for a court/legal matter. If for any reason I am expected to attend/participate in a court/legal matter a fee of $400 up front for participation plus an additional fee of $400/hour for court appearances and/or waiting for a court proceeding, and a fee of $5 per minute will be charged for all time spent related to the court/legal matter (this includes: phone calls, email, and/or paperwork).

CONSENT FOR MENTAL HEALTH CARE
I, the undersigned, agree and consent to the above policies, and I agree to participate in the mental health care offered and provided by Megan Knueve, LCSW, a mental health professional as defined by Indiana law. I understand that I am consenting and agreeing only to those mental health services that Megan Knueve, LCSW is qualified to provide within the scope of her professional license, certifications, and training, and I am free to discontinue services at any time.
I ______________________(enter full name below) have read the above and I understand the information and agreements stated. I consent to receive counseling, coaching, support services from Megan Knueve, LCSW according to the guidelines noted.