Middleton Psychology Services, LLC

navigating complexity, building resilience

Regarding Telehealth and Covid-19 Precautions:

For any of a number of reasons, you may decide to participate in telehealth treatment instead of an-person session or in addition to an in-person session.  Although a relatively new means of providing services, many people describe finding the approach satisfactory.  As with treatment in general, it’s important for participants to understand the risks and benefits of telehealth and fully agree to engage in this modality.  Of course, we cannot anticipate all possible concerns associated with telehealth, so we ask that by your signature below, you are unconditionally accepting responsibility for any anticipated or unforeseen issues, negative consequences, or damages that might occur by virtue of telehealth services and you hold your therapist, Middleton Psychology Services, and all associates harmless now and in the future.

Even if you initially agree to participate in telehealth, you may withdraw your consent by informing your therapist and refusing to continue the service at any time.  

Privacy cannot be as readily assured with telehealth as it can be in the office setting.  Your therapist will establish a private location on their end, but it is up to you to ensure privacy in your setting.  For instance, we recommend against planning to have a telehealth session where you set-up in an area with public WiFi, such as a coffee bar.  As such, participants bear the responsibility of ensuring privacy/confidentiality with regard to potential eavesdropping from others wherever you set-up your end of the connection.  Likewise, we cannot guarantee anything with regard to the security of your electronic equipment (i.e., computer).  If your system has been compromised in some way, as with a computer virus, we will not know that and we cannot do anything about it.  We recommend you have a good malware protection service that helps with the privacy/security of your computer (e.g., Norton, McAfee).

We use Doxy Me, a free telehealth platform, for the provision of telehealth services.  Each therapist sets up an account via Doxy Me that has a unique web address for that particular provider’s “virtual waiting room.”  To begin a session, patients enter the web address of their therapist’s virtual “waiting room” their browser.  Your virtual presence in the waiting room with appear on the therapist’s screen and the therapist will then open the door to the session when they’re ready.  Doxy Me serves as an independent contractor and we do not have any control over the security of their system.  They may have security breaches that compromise the privacy of your protected health information.  If that happens, Doxy Me will inform us and provide options for managing the situation.  We ask that you accept all risks associated with using Doxy Me. 

Interacting with your therapist via telehealth will inevitably miss some important elements of in-person interactions.  For instance, nonverbal communication may not be as evident.

Some insurance companies may not cover telehealth sessions.  You will be responsible for covering the costs of your sessions, which are the same rates as in-person sessions, so you may want to check to see if telehealth is covered with your plan.

Important points to note with regard to telehealth services:

I understand that telemedicine/telehealth/teletherapy includes consultation, treatment, transfer of medical data, e-mails, telephone conversations and/or education using interactive audio, video, or data communications.
I understand that telehealth involves the communication of my medical/mental health information, both orally and/or visually.
I understand that there are potential risks to this technology despite best efforts to ensure high encryption and secure technology on the part of my provider and/or business associates such as DoxyMe, including interruptions, unauthorized access, and technical difficulties.
I understand that the laws that protect the confidentiality of my medical information also apply to telehealth.  As such, I understand that the information I disclose during therapy or consultation is generally confidential; however, there are both mandatory and permissive exceptions to confidentiality as discussed in our intake and delineated elsewhere.
I understand if people other than my health care provider are present, I will be informed of this and the others will be asked to respect privacy concerns.
I understand that my healthcare provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are inadequate for the purpose.
I accept that telehealth does not provide emergency service.  If I am experiencing an emergency, I understand that I can call 911 or proceed to the nearest hospital emergency room for help.
I understand there is a risk of being overheard by anyone near me if I am not careful to ensure privacy (e.g., being in a private room).  I am responsible to providing the necessary computer with audio and visual capability, telecommunications equipment and internet access for telehealth sessions, internet/computer security on my end, having sufficient lighting, and ensuring privacy and freedom from distractions or intrusions on my end.
I understand I am not allowed to make an audio and/or video recording of the telesession without the signed consent of the provider.  Violation of this constraint is illegal. 

Procedures for when we return to the physical office if/when that appears indicated:

· If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
· You will take steps between appointments to minimize your exposure to COVID.
· If you have a job that exposes you to other people who are infected, you will immediately let me [and my staff] know.
· If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me [and my staff] know.
· If a resident of your home tests positive for the infection, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth.

We may change the above precautions if additional local, state or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.

OurCommitment to Minimize Exposure:  Middleton Psychology Services has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts.

If You or Your Therapist Are Sick:  You understand that we are committed to keeping you, we and all of our families safe from the spread of this virus. If you show up for an appointment and your therapist or office staff believe you have a fever or other symptoms, or believe you have been exposed, we ask you to leave the office immediately and we can follow up with services by telehealth as appropriate.
If your therapist or a staff member test positive for the coronavirus, we will notify you so that you can take appropriate precautions.
Your Confidentiality in the Case of Infection: If you test positive for the coronavirus, we may be required to notify local health authorities that
you have been in the office. If we have to report this, we will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits.

For your information, our Physical Office Safety Precautions in Effect During the Pandemic include:

· Office seating in the waiting room and in therapy/testing rooms has been arranged for appropriate physical distancing.
·  Our staff will use masks.
·  Our staff maintains safe distancing.
·  Restroom soap dispensers are maintained and everyone is encouraged to wash their hands.
·  Hand sanitizer is available.
· We schedule appointments at specific intervals to minimize the number of people in the waiting room.
· We ask all patients to wait in their cars or outside until no earlier than 5 minutes before their appointment times.
·  Credit card pads, pens and other areas that are commonly touched are thoroughly sanitized after each use.
· Physical contact is not permitted.
· Tissues and trash bins are easily accessed. Trash is disposed of on a frequent basis.
· Common areas are thoroughly disinfected at the end of each day.

MP​S and your therapist will treat with great care all the protected health information (PHI) you provide.  We use an Electronic Medical Records service called TherapyNotes.  For the most part, we keep your information private.  The age of consent for treatment in Maryland is 16, so patients younger than 16 must have parent involvement in treatment and access to associated PHI.  We adhere to standard privacy practices, including the Health Information Portability and Accountability Act (HIPAA) and the Health Information Technology for Clinical and Economic Health (HITECH) Act compliance, recommended by the Department of Health and Human Services (HHS).  Accordingly, the following serves as our Notice of Privacy Practices:

 You may:

Get a copy of your paper or electronic medical record at a reasonable fee for time and resources
Comment to clarify or correct your paper or electronic medical record by adding to the record (records cannot be deleted) 
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint regarding your privacy

 You have some choices in the way that we use and share information as we:

Tell family and friends about your condition
Provide disaster relief
Provide mental health care

We may use and share your information as we:

Treat you
Run our organization
Bill for your services
Help with public health and safety issues
Comply with the law
Address workers’ compensation, law enforcement, and other government requests, with proper judicial authority
Respond to lawsuits and legal actions

When it comes to your health information, you have certain rights.  This section explains your rights and some of our responsibilities to help you:

For a reasonable fee to cover materials and time, you can see or get an electronic or paper copy of your medical record/health information we have about you, other than psychotherapy notes or information we believe would prove harmful in some way. 
We will provide a copy or a summary of your health information, usually within 30 days of your request.
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.  We may say “no” to your request, but we’ll tell you why in writing within 60 days.

You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.  We will say “yes” to all reasonable requests.
You can ask us not to use or share certain health information for treatment, payment, or our operations.  We are not required to agree to your request, and we may say “no” if it would affect your care or if it violates law or ethics.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer.  We will say “yes” unless a law requires us to share that information.
You can ask for a list (accounting) of the times we’ve shared your PHI for six years prior to the date you ask, who we shared it with, and why.  We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).  We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.  We will provide you with a paper copy promptly.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.  We will make sure the person has this authority and can act for you before we take any action.

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/.  We will not retaliate against you for filing a complaint.

If you have a clear preference for how we share your information in the situations described below, talk to us.  Tell us what you want us to do, and we will follow your instructions.  In these cases, you have both the right and choice to tell us to:

Share information with your family, close friends, or others involved in your care
Share information in a disaster relief situation
Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

Marketing purposes
Sale of your information
Most sharing of psychotherapy notes

We typically use or share your health information in the following ways:

1. We can use your health information and share it with other professionals who are treating you.
    Example: A doctor treating you for an injury asks another doctor about your overall health condition.
2. We can use and share your health information to run our practice, improve your care, and contact you when necessary.
    Example: We use health information about you to manage your treatment and services.
3. We can use and share your health information to bill and get payment from health plans or other entities.
    Example: We give information about you to your health insurance plan so it will pay for your services.
4. We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research.  We have to meet many conditions in the law before we can share your

    information for these purposes.  See: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
5. We can share health information about you for certain situations such as:
    Preventing disease
    Helping with product recalls
    Reporting adverse reactions to medications
    Reporting suspected abuse, neglect, or domestic violence
    Preventing or reducing a serious threat to anyone’s health or safety
6. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
7. We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
8. We can use or share health information about you:
    For workers’ compensation claims
    For law enforcement purposes or with a law enforcement official if they have proper judicial authorization
    With health oversight agencies for activities authorized by law
    For special government functions such as military, national security, and presidential protective services
    In response to a court or administrative order, or in response to a subpoena

We maintain the privacy and security of your protected health information.

We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it if you want it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

HHS can change the terms of this notice, and the changes will apply to all information we have about you.  The new notice will be available upon request, in our office, and on our web site.

To further clarify limits to confidentiality regarding your psychotherapy treatment at MPS, please note:

In couples counseling and group psychotherapy, we encourage members to respect to privacy of other treatment participants, but your therapist cannot ensure any given treatment participant will respect confidentiality and privacy.  Although a person will not be invited to participate in couples or group treatment unless they sign a promise not to reveal participant names or therapy content, she may violate her promise.  Should the therapist become aware of such a breech, the offending individual will be removed from group therapy or the issue will be addressed in a couples’ session with the therapist and the respective couple deciding how to address it.
If you were sent to MPS by a court or an employer for evaluation or treatment (other than related to competency), the court or employer expects a report from us.  If this is your situation, please let us know at the outset.  Once you share information in this kind of situation, we cannot retract it (i.e., it will be in the report if it is relevant).  

Competency evaluations present a number of additional complexities, which require a separate, specialized informed consent.

If there’s a subpoena or court order, we must provide whatever’s requested.  Are you involved in a lawsuit?  Have you been charged with a crime?  If so, and you introduce your mental health treatment to the court for something related to the case (i.e., you claim to have suffered emotional damage in your lawsuit or you’re asking the court to consider mental health mitigating circumstances in your commission of a crime), we may then be ordered to provide the court our records, to testify, or to write a report.  Please consult your lawyer about this kind of situation.
Even in the absence of a verbalized threat, if your therapist or an agent of MPS believes you present an imminent, serious threat of harm to yourself or another person, we will try to protect you or the potential victim (consistent with what we would expect any caring person to do, but also as required by law and ethics for therapists).  This can mean inpatient psychiatric hospitalization, contacting authorities like the police, and informing potential victims. 
If your therapist or an agent of MPS believes a child, a senior, or a handicapped person has been or will be abused or neglected, we must report this to the authorities.
When your therapist is away, another trusted, licensed professional therapist may stand-in or be available to help should something urgent arise.  She will access your records and follow the same procedures under the same constraints with regard to privacy and confidentiality.
In the interests of optimal care, your therapist will consult other licensed helping professionals, as needed.  These professionals follow the same procedures under the same constraints with regard to privacy and confidentiality.  When consulting, your therapist avoids using your name and limits information to only as much as is needed to communicate the treatment issue.
If you have third-party payment for services (like an insurance company), we must exchange whatever treatment-related protected health information (PHI) they require to make their payments to MPS on your behalf.  Your signature immediately below this paragraph authorizes us to share clinical information on your treatment with your insurance company.  If you do not authorize communication of treatment-related information with your insurance company, you accept responsibility to make full and prompt payment of your bill for services provided and we will respect your wishes.  Mark as appropriate below and sign next to your choice:

Be aware that should you indicate information about your treatment or receipt of services at MPS on social media sites, you can never reasonably expect to retract that disclosure, even if you later remove the information from the particular site.  Also, if you acknowledge your therapist in public, such as with a greeting or a wave, others may infer you know the clinician from participation in treatment (your therapist will defer direct queries by third parties and “neither confirm nor deny” your participation if asked if he sees you as a patient).paragraph here.