Client Policy
​Emergencies/Crisis: If there is an emergency during our work together, or in the future after termination where my provider becomes concerned about your personal safety, the possibility of me injuring someone else, or about me receiving proper psychiatric care, s/he will do whatever s/he can, within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For this purpose, s/he may also contact the person whose name I have provided on the biographical sheet.
Health Insurance & Confidentiality of Records: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. In order to have appointments authorized, your provider may need to share mental health information including but not limited to: verbal or oral communication of diagnosis, presenting problem, symptoms, progress notes, and treatment plan.
Litigation Limitation: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (client) nor your attorney, nor anyone else acting on your behalf will call on your provider to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.
Consultation: Your provider consults regularly with other professionals regarding his/her clients; however, the client's identity remains completely anonymous, and confidentiality is fully maintained.
Records and Your Right to Review Them: Both the law and the standards of my profession require that I keep appropriate treatment records. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when your provider assesses that releasing such information might be harmful in any way. In such a case your provider will provide the records to an appropriate and legitimate mental health professional of your choice.* Considering all of the above exclusions, if it is still appropriate, upon your request, your provider will release information to any agency/person you specify unless your clinician assesses that releasing such information might be harmful in any way.
Telephone & Emergency Procedures: If you need to contact your provider between sessions, please leave a message on their answering service and your call will be returned as soon as possible. Your provider checks his/her messages a few times during the daytime only, unless he is out of town. If a medical emergency situation arises, your clinician is not intended to be used in the event of an emergency. For medical emergencies, you should call 911 or have someone take you to the nearest emergency room. If you are experiencing a non-medical mental health crisis, you may dial 988 (the Suicide and Crisis Lifeline) or chat at https://988lifeline.org/chat/. Please do not use e-mail or faxes for emergencies as your clinician does not always check his/her e-mail and faxes may not have been received.
Payments & Insurance Reimbursement: Private pay clients are expected to pay the standard fee quoted at the time of intake unless arrangements have been made or there is a previous agreement with your insurance company. ALL clients with an insurance co-pay or private pay are required to have a working credit card on file at all times while you are a client of Family Adult Child Therapy Services (FACTS) PLLC. It is your responsibility to verify the specifics of your coverage. If the client account is overdue (unpaid) and there is no written agreement on a payment plan, your provider can use legal or other means (courts, collection agencies, etc.) to obtain payment. Non-payment of 3 or more invoices may result in temporary suspension of treatment. If the client is facing financial difficulty, it is the client’s responsibility to communicate so with their provider and discuss a plan of payment that does not violate the 3-invoice client payment policy. In efforts to ensure that the client’s treatment is not interrupted due to the said violations, clients should contact their provider at their earliest convenience to communicate the said violation.
The Process of Therapy/Evaluation and Scope of Practice: Your provider provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within his or her scope of practice but may refer you to the appropriate professional (ex. Lawyer or physician) for the said services. Your clinician does not complete applications for FMLA but rather can provide a statement in the form of a written letter to your physician or employer about your diagnosis/reason for treatment and/or status of treatment.
Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, your provider will discuss with you (client) his/her working understanding of the problem, treatment plan, therapeutic objectives and his/her view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, your provider’s expertise in employing them or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.
Termination: As set forth above, your provider will assess if s/he can be of benefit to you. Your provider does not accept clients who, in his/her opinion, s/he cannot help. In such a case s/he will give you a number of referrals, who you can contact. If at any point during psychotherapy, your provider assesses that s/he is not effective in helping you reach the therapeutic goals, s/he is obligated to discuss it with you and, if appropriate, to terminate treatment. In such a case s/he would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, your provider will talk to the psychotherapist of your choice in order to help with the transition. If at any time you want another professional’s opinion or wish to consult with another therapist, your provider will assist you in finding someone qualified, and if s/he has your written consent, s/he will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, your provider can offer to provide you with names of other qualified professionals whose services you might prefer.
Cancellation Policy: In order to provide the best service possible and ensure the needs of clients are being met, the following cancellation policy has been implemented:
· If you need to cancel or reschedule a session, you must notify your therapist at least 24 hours in advance.
· If you do not show up for a scheduled session or if you cancel with less than 24 hours' notice, a $100 out-of-pocket fee will be billed directly to you. This will not be covered by your insurance company and the same fee applies for private pay clients.
We understand that emergencies do happen and will make exceptions to this policy in the case of emergencies upon the first cancellation due to an emergency. However, frequent cancellations interrupt the effectiveness of treatment. Therefore, any further late cancellations, 3 or more cancellations in a 60-day period, or 2 consecutive cancellations will result in the termination of treatment and the cancellation fee will be applied.
To cancel an appointment, please call and leave a voicemail, send a text message (if it is an emergency), or send an email to avoid a No Show/Late Cancel charge of $100. These forms of communication are time stamped and will be considered when assessing the late fee.
Most insurance companies do not reimburse for missed sessions so the client will pay out of pocket.
Privacy Policy
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.
Family Adult Child Therapy Services PLLC (the practice) is committed to protecting your privacy. The Practice is required by federal law to maintain the privacy of Protected Health Information (“PHI”), which is information that identifies or could be used to identify you. The Practice is required to provide you with this Notice of Privacy Practices (this “Notice”), which explains the Practice's legal duties and privacy practices and your rights regarding PHI that we collect and maintain.
YOUR RIGHTS
Your rights regarding PHI are explained below. To exercise these rights, please submit a written request to the Practice at the address noted below.
To inspect and copy PHI.
• You can ask for an electronic or paper copy of PHI. The Practice may charge you a reasonable fee.
• The Practice may deny your request if it believes the disclosure will endanger your life or another person's life. You may have a right to have this decision reviewed.
To amend PHI.
• You can ask to correct PHI you believe is incorrect or incomplete. The Practice may require you to make your request in writing and provide a reason for the request.
• The Practice may deny your request. The Practice will send a written explanation for the denial and allow you to submit a written statement of disagreement.
To request confidential communications.
• You can ask the Practice to contact you in a specific way. The Practice will say “yes” to all reasonable requests.
To limit what is used or shared.
• You can ask the Practice not to use or share PHI for treatment, payment, or business operations. The Practice is not required to agree if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask the Practice not to share PHI with your health insurer.
• You can ask for the Practice not to share your PHI with family members or friends by stating the specific restriction requested and to whom you want the restriction to apply.
To obtain a list of those with whom your PHI has been shared.
• You can ask for a list, called an accounting, of the times your health information has been shared. You can receive one accounting every 12 months at no charge, but you may be charged a reasonable fee if you ask for one more frequently.
To receive a copy of this Notice.
• You can ask for a paper copy of this Notice, even if you agreed to receive the Notice electronically.
To choose someone to act for you.
• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights.
To file a complaint if you feel your rights are violated.
• You can file a complaint by contacting the Practice using the following information:
Family Adult Child Therapy Services (FACTS) PLLC
125 S Wacker Drive Suite 300
Chicago, IL 60606-4421
Phone: (312) 835-7039
Fax: (469) 421-8594
Email: contact@factspllc.com
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• The Practice will not retaliate against you for filing a complaint.
To opt out of receiving fundraising communications.
• The Practice may contact you for fundraising efforts, but you can ask not to be contacted again.
OUR USES AND DISCLOSURES
1. Routine Uses and Disclosures of PHI
The Practice is permitted under federal law to use and disclose PHI, without your written authorization, for certain routine uses and disclosures, such as those made for treatment, payment, and the operation of our business. The Practice typically uses or shares your health information in the following ways:
To treat you.
• The Practice can use and share PHI with other professionals who are treating you.
• Example: Your primary care doctor asks about your mental health treatment.
To run the health care operations.
• The Practice can use and share PHI to run the business, improve your care, and contact you.
• Example: The Practice uses PHI to send you appointment reminders if you choose.
To bill for your services.
• The Practice can use and share PHI to bill and get payment from health plans or other entities.
• Example: The Practice gives PHI to your health insurance plan so it will pay for your services.
2. Uses and Disclosures of PHI That May Be Made Without Your Authorization or Opportunity to Object
The Practice may use or disclose PHI without your authorization or an opportunity for you to object, including:
To help with public health and safety issues
• Public health: To prevent the spread of disease, assist in product recalls, and report adverse reactions to medication.
• Required by the Secretary of Health and Human Services: We may be required to disclose your PHI to the Secretary of Health and Human Services to investigate or determine our compliance with the requirements of the final rule on Standards for Privacy of Individually Identifiable Health Information.
• Health oversight: For audits, investigations, and inspections by government agencies that oversee the health care system, government benefit programs, other government regulatory programs, and civil rights laws.
• Serious threat to health or safety: To prevent a serious and imminent threat.
• Abuse or Neglect: To report abuse, neglect, or domestic violence.
To comply with law, law enforcement, or other government requests
• Required by law: If required by federal, state or local law.
• Judicial and administrative proceedings: To respond to a court order, subpoena, or discovery request.
• Law enforcement: For law locate and identify you or disclose information about a victim of a crime.
• Specialized Government Functions: For military or national security concerns, including intelligence, protective services for heads of state, or your security clearance.
• National security and intelligence activities: For intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
• Workers' Compensation: To comply with workers' compensation laws or support claims.
To comply with other requests
• Coroners and Funeral Directors: To perform their legally authorized duties.
• Organ Donation: For organ donation or transplantation.
• Research: For research that has been approved by an institutional review board.
• Inmates: The Practice created or received your PHI in the course of providing care.
• Business Associates: To organizations that perform functions, activities or services on our behalf.
3. Uses and Disclosures of PHI That May Be Made With Your Authorization or Opportunity to Object
Unless you object, the Practice may disclose PHI:
To your family, friends, or others if PHI directly relates to that person's involvement in your care.
If it is in your best interest because you are unable to state your preference.
4. Uses and Disclosures of PHI Based Upon Your Written Authorization
The Practice must obtain your written authorization to use and/or disclose PHI for the following purposes:
Marketing, sale of PHI, and psychotherapy notes.
You may revoke your authorization, at any time, by contacting the Practice in writing, using the information above.
The Practice will not use or share PHI other than as described in Notice unless you give your permission in writing.
OUR RESPONSIBILITIES
• The Practice is required by law to maintain the privacy and security of PHI.
• The Practice is required to abide by the terms of this Notice currently in effect. Where more stringent state or federal law governs PHI, the Practice will abide by the more stringent law.
• The Practice reserves the right to amend Notice. All changes are applicable to PHI collected and maintained by the Practice. Should the Practice make changes, you may obtain a revised Notice by requesting a copy from the Practice, using the information above, or by viewing a copy on the website: www.factspllc.com.
• The Practice will inform you if PHI is compromised in a breach.
This Notice is effective on April 24, 2024.
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