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Terms and Policy

HIPPA Privacy Form
IHS Psychotherapy and Counseling, LLC

Notice of Policies & Practices to Protect the Privacy of your Health Information (HIPPA Consent)
Notice of Psychotherapists’ Policies and Practices to Protect the Privacy of the Patient’s Health

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations
IHS Psychotherapy and Counseling, LLC (IHS) may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your written authorization. To help 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 IHS therapists provide, coordinate, or manage your mental/behavioral health care and other services related to your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician, psychiatrist or another psychologist.
-Payment is when IHS releases an invoice to you to obtain insurance reimbursement that contains diagnosis codes for diagnosing and cpt codes which describes the type of therapy. This information constitutes PHI information.
– Health Care Operations are activities that relate to the performance and operation of (IHS). Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
“Use” applies only to activities within IHS, such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of IHS such as releasing, transferring, or providing access to information about you to other parties.
“Authorization” is your written permission to disclose confidential mental health information. All authorizations to disclose must be on a specific legally required form.

II. Other Uses and Disclosures Requiring Authorization

Therapists may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. In those instances when the therapist is asked for information for purposes outside of treatment, payment, or health care operations, your IHS therapist will obtain an authorization from you before releasing this information.
You may revoke all authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) IHS staff have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage. The law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures without Authorization

Therapists may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse – If a therapist has reason to believe that a child has been subjected to abuse or neglect, he/she must report this belief to the appropriate authorities.
Health Oversight Activities – If IHS receives a subpoena from the Maryland Board of Professional Counselors because they are investigating IHS Psychotherapy and Counseling LLC or Norma Stevens, MS, LCPC, we must disclose any PHI requested by the Board.

Judicial and Administrative Proceedings – If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment or the records thereof, such information is privileged under state law, and will not be released without your written authorization or a court order. The privilege does not apply when you are being evaluated by a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.

Serious Threat to Health or Safety – If you communicate to your therapist a specific threat of imminent harm against another individual or if your therapist believes that there is clear, imminent risk of physical or mental injury being inflicted against another individual, the therapist may make disclosures that he/she believes are necessary to protect that individual from harm. If the therapist believes that you present an imminent, serious risk of physical or mental injury or death to yourself, he/she may make disclosures that he/she considers necessary to protect you from harm.

IV. Patient’s Rights and Psychotherapist’s Duties

Patient’s Rights:

Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, IHS is not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations –You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are receiving services at IHS. On your request, your bills will be sent to another address you provide.

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. Therapists at IHS may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, your therapist will discuss with you the details of the request and denial process for PHI.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. Therapists at IHS may deny your request. On your request, your therapist will discuss with you the details of the amendment process.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. On your request, your therapist will discuss with you the details of the accounting process.

Right to a Paper Copy – You have the right to obtain a paper copy of the notice upon request, even if you have agreed to receive the notice electronically.

Psychotherapist’s Duties:

Therapists are required by law to maintain the privacy of PHI and to provide you with a notice of legal duties and privacy practices with respect to PHI. IHS Psychotherapy and Counseling, LLC reserves the right to change the privacy policies and practices described in this notice. Unless you are notified of such changes, however, IHS Psychotherapy and Counseling, LLC is required to abide by the terms currently in effect. If any policies and procedures are revised, they will be posted in the waiting room and given to you upon your next visit on or after the effective date.

V. 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 Norma Stevens, MS, LCPC of IHS Psychotherapy and Counseling, LLC by telephone or mail.

You may also send a written complaint to:

Secretary of the U.S. Department of Health and Human Services
Office of the Secretary,
Hubert Humphrey Building
2000 Independence Avenue, S.W.
Washington, D.C. 20201
(tel) 202 690-7000

VI. Effective Date, Restrictions, and Changes to Privacy Policy: This notice will go into effect on February 1, 2013.
IHS Psychotherapy and Counseling, LLC reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that it maintains. The new Notice Provisions will be posted in the waiting room and given to you at your next visit upon or after the effective date of the changes.
( Type Full Name )
IHS Consent
Norma Stevens, MS, NCC, LCPC IHS Psychotherapy and Counseling, LLC 6011 University Boulevard, Suite 100 Ellicott City, MD 21043
At IHS Psychotherapy and Counseling, it is important in beginning our professional counseling relationship for you to understand both its nature and its limitations. Please review this document, sign where appropriate, and do not hesitate to ask any questions.
HIPPA CONSENT FORM: I have been provided a copy of the "Notice of Policies & Practices to Protect the Privacy of your Health Information" (also known as "HIPPA Consent") form and understand that it describes how psychological and medical information about me may be used or disclosed and how I can gain access to this information.
CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission, except where disclosure is required by law.
When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by law are: where there is a reasonable suspicion of child, vulnerable adult or elder abuse or neglect; and where a client presents an imminent threat of danger to him/herself or others. Your therapist may contact the emergency contact you designate as well as any other persons necessary to ensure your safety and the safety of others who may be at risk.
When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by your therapist.
Health Insurance & Confidentiality of Records: Your health insurance carrier may require the disclosure of confidential information in order to process your claims. I authorize Norma Stevens and IHS Psychotherapy and Counseling LLC to provide information to insurance companies to process my reimbursement claims.
Signature:_______________________________________________________ !1
We do not have control or knowledge over what insurance companies do with the information or who has access to this information once it reaches your insurance carrier. (See HIPPA Privacy document.)

Electronic Medical Record System: I hereby authorize my practitioner and IHS Psychotherapy and Counseling, LLC to retain all of my medical and behavioral health records/information in an electronic format stored in a cloud. These records will be maintained in a secured, confidential manner and shall be in compliance with HIPPA Regulations for patient confidentiality. These records shall not be released without consent of the patient. This authorization remains in effect until revoked in writing.

Supervision/Consultation: To practice ethically and effectively, your therapist may consult with other therapists or professional colleagues on how to best serve you. Personal identifying information is not disclosed in these discussions.

Appointment reminders by text or email: IHS is able to provide optional automated email and text reminders of your appointments. I understand that these are not sent encrypted and therefore have risks including, but not limited to confidentiality in treatment and transmitting my protected health information by unsecured means. I authorize IHS Psychotherapy and Counseling LLC to provide automated appointment reminders through text and email by signing below.   You can OPT OUT of this service at any time by informing your therapist in writing.


Email and Texting:
E-mail and texting are not secure and can compromise the privacy and confidentiality of PHI. IHS recommends leaving messages securely through your client portal. IHS staff are happy to assist you in the use of this system particularly resetting usernames and passwords. The link to the portal can be accessed through the website

The email address is an encrypted email address. While you transmit a message to it, your message may not be secure. The response to your message will be encrypted and messages are stored in a HIPPA compliant manner. If you send your IHS therapist an email, you acknowledge and accept the risks and limits to the privacy of your protected health information.

Email responses are returned during the hours of 9:00 am to 7:00 pm and may take up to 48-72 hours to respond. Do not contact your therapist by email if you have an urgent matter; please call. If you have an emergency, please call 911 or go to your nearest emergency room.

Payment for Services: Payment for services is due at the beginning of each session. We accept cash, checks and major credit cards. Checks can be made out to IHS Psychotherapy and Counseling, LLC or IHS P&C. There is a $35 fee for returned checks.
Standard IHS Fees are as follows: $135 for a 60 minute individual appointment and $205 for a 90 minute couples appointment and $145 for a 60 minute couples appointment.
Insurance Reimbursement:
IHS Psychotherapy and Counseling LLC does not participate with any insurance companies. It is the responsibility of the client to obtain information about their insurance plan and benefits
and to submit all claims for reimbursement. We would be happy to provide you with relevant information when checking with your insurance company about benefits.
Cancellation Policy:
Your therapist has reserved time specifically for you for each session. Sessions must be cancelled at least 24 hours in advance of your appointment. To cancel your appointment, please leave a message on voicemail. Sessions missed without a 24 hour notice will incur a $75 missed appointment fee.  Please note this fee is not covered or reimbursed by insurance.  In the case of inclement weather, you will not be charged any fees if there is less than a 24 hour notice, but you must still call.
Psychotherapy is a complex process involving many variables. It does not work for everyone, and there is no guarantee. Your therapist promises to have been trained and licensed as a professional, to reserve a specific time for you, to plan for each session, to actively listen, and to give constructive feedback.
You as the client are asked to attend each session, to spend the time between sessions reflecting upon or trying out that which has emerged in each session, and to talk in each session about the issues and experiences which trouble you.
While every effort will be made to reduce presenting symptoms, you may experience discomfort and uncomfortable emotions at times as you address your concerns and issues and redefine your personal goals. It is possible that you may not reach your therapeutic goals. Please inform Norma Stevens, MS, LCPC of any complaints or concerns you have. Every effort will be made to address your concerns. If you are not satisfied, we would be happy to provide referrals to other professionals upon your request. You have a right to terminate therapy at any time. We recommend processing your termination with your therapist.  If you discontinue attending therapy and not contact your therapist for more than 30 days, you are considered terminated from therapy. 

IHS may provide referrals to other professionals during the course of therapy. IHS does not have control over any other professional's behavior nor does IHS have any control over the process or outcome of any work you might do with a professional to whom we refer you; and thus, we cannot be held liable.

SERVICES ASSOCIATED WITH LEGAL ISSUES AND/OR COURT PROCESS Limits of Feedback: Licensed Clinical Professional Counselors are not licensed to conduct psychological testing; therefore, therapists are unable to render feedback re: a client's
psychological structure or stability. For psychological evaluations, we will be happy to provide referrals to Licensed Psychologists.
IHS Psychotherapy and Counseling LLC does not perform court evaluations nor do they appear in court on behalf of individuals, couples, children or adults. IHS Psychotherapy and Counseling LLC clinicians are not trained for, nor do they maintain records with the intended purpose of court involvement.
-In addition, the legal process is such that we may be compelled to reveal information about you that could affect you negatively or undermine your relationship with your therapist. Because the therapist/client relationship is built on trust with the foundation of that trust being confidentiality, it is often damaging to the therapeutic relationship for the therapist to be asked to present records to the court, testify whether factual or in an expert nature, in court or deposition.
-If you wish forms for determination of mental illness, disability, court involvement with custody or assessments to be completed for you or your family, we would be happy to refer you to practitioners in the area who offer this service.

Fees & Payment: Consultation with lawyers or other professionals, including telephone, written responses and e-mail will incur a fee of $500 per hour per 15 minute increments or any part thereof. Therapists do not appear in court unless court ordered by a judge. Regarding court appearances, responding to subpoenas, depositions, affidavits, and case preparation, the fee is $500 per hour plus expenses. Charges are billed based on 1/2 hour increments, pro-rated with a minimum of 2 hours. Travel time to and from court appearances and depositions will also be billed at the aforementioned hourly rate as well. I/we understand and agree that I/we accept financial responsibility for such activity and will give at least 48 hours advance notice of change or cancellation, to not incur the two hour minimum fee. Payment is due one week prior to the scheduled appearance or deposition/consultation. If you have been seen as a couple, and records are subpoenaed, both partners need to sign the authorization for release of the records unless court ordered.

SOCIAL MEDIA POLICY: In order to protect your confidentiality and maintain appropriate therapeutic boundaries, therapists do not accept friend requests nor initiate friend requests to current or former clients on social media sites such as Facebook, LinkedIn, etc... We do not solicit client testimonials or comments on our website or blog. If clients wish to make a comment on a blog post, they are encouraged to do so anonymously.

IN CASE OF EMERGENCY: We do NOT provide emergency care services, acute in-patient care, and do NOT have a 24 hour answering service. Messages you leave for your therapist may not be retrieved until the following business day. If you have an emergency and cannot get a hold of your therapist, please call 911 or go to your nearest emergency room. You can also call The Howard County Mobile Crisis Team at (410) 531-6677, The Baltimore County Mobile Crisis team at 410-931-2214, Anne Arundel County Crisis Warmline: 410-768-5522.

National Suicide Prevention Hotlines

1-800-SUICIDE (784-2433)

1-800-273-TALK (8255)

This information is required by the Maryland Board of Professional Counselors and Therapists which regulates all licensed clinical professional counselors. The Board's contact information is:  The Maryland Board of Professional Counselors and Therapists, 4201 Patterson Avenue, Baltimore, MD 21215-2299, 410-764-4732.

I have been provided a copy of the HIPPA policies and practices and agree to the office policies of IHS Psychotherapy and Counseling LLC.

__________________________________________________________ Signature of Client
__________________________________________________________ Printed name of Client
__________________________________________________________ Signature of Client
__________________________________________________________ Printed name of Client
___________________________________________________________ Signature of Therapist IHS Psychotherapy and Counseling, LLC
Norma Stevens, MS, NCC, LCPC
( Type Full Name )
Informed Consent for Telehealth Services

IHS Psychotherapy and Counseling LLC
Norma Stevens, MS, LCPC
6011 University Blvd., Suite 100
Ellicott City, MD 21043

Informed Consent for Telehealth Services

Definition of Telehealth: Telehealth involves the use of electronic communications to enable IHS Psychotherapy and Counseling LLC, Norma Stevens, LCPC to connect with individuals using live interactive video and audio communications. Telehealth includes the practice of psychological health care delivery, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

I understand that I have rights with respect to telehealth:

1. The laws that protect the confidentiality of my personal information that I have already signed also apply to telehealth. Copy of our Office Policies and Therapeutic Informed Consent can be provided.

2. I understand that I have the right to withhold or withdraw my consent to the use of telehealth in the course of my care at any time, without affecting my right to future care or treatment.

3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of IHS Psychotherapy and Counseling LLC, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons. IHS Psychotherapy and Counseling LLC utilizes secure, encrypted HIPAA compliant audio/video transmission software to deliver telehealth via Zoom Healthcare version.

4. I understand that Teletherapy based services and care may not be as complete as face to face services.  The risk that non-verbal and verbal cues will be missed is naturally greater.  Therefore, repair may be necessary in the context of the therapeutic relationship and Norma Stevens, MS, LCPC will welcome the opportunity to process, repair and clarify the intended messages during the session.  

5. By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for audio-/video-/computer-based psychotherapy services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care facility in my immediate area.

Payment for Telehealth Services:
If you submit to your insurance for reimbursement, it is in your best interest to contact your insurance company directly to confirm that they will cover teletherapy services.  Ultimately, the client is responsible for payment and agrees to pay in accordance with the regular rates and terms in effect at the present time.  Payment can be made by credit card or mailing a check either yourself or through online banking.  Cash cannot be accepted at this time.  

Patient Consent to the Use of Telehealth:
I have read and understand the information provided above regarding telehealth.   I understand that the use of telehealth is optional.   I have read this document carefully and understand the risks and benefits related to the use of telehealth services.

I hereby give my informed consent to participate in the use of telehealth services for treatment under the terms described herein. By my signature below, I hereby state that I have read, understood, and agree to the terms of this document.


Client's Signature/Date __________________________________


Therapist's Signature/Date __________________________________

( Type Full Name )
Preparation for Video Sessions - Tips
Creating Confidential Space

Things to consider:
Is the space private?
Can you lock the door?
If not, will others who have access to the space respect your request for privacy and not enter the room?
Can you/have you had a conversation with them?
Were they receptive?
Can others outside the room hear you talking?
If so, can you create white noise with a fan or other form of background noise? (Preferably placed outside the doorway of the room you're in)
Consider using headphones or earbuds so that your provider's voice is kept private and is only heard by you
If you have a hard time finding confidential space, here are some examples that others have used. These are not ideal, but should be considered secondary choices if an ideal setup is not available. If you use any of these, please make sure that the space is comfortable to you. Being comfortable is also highly important.
Laundry Room
Actual last resort: your car parked in safe, private spot. (We want to emphasize that private does not mean secluded. Please do make sure you are in a safe location.)

Technical Setup:
A laptop or desktop computer are ideal - preferably the biggest screen size that you have available to you (that you can also have in a comfortable, confidential space)
If you're using a tablet or phone, please prop up the device so that it is stable and that the camera is about level with your eyes
Whatever device you're using, please make sure that the camera is about level with your eyes. It may require propping up your device or monitor on other items, such as books.
Please make sure that you're well-lit and don't have a bright light source directly behind you; natural light coming from behind your monitor will make you most easily seen.
When you can see me, "blow me up" - make the window where I appear as large as possible. You may have to drag its edges for this to happen.
Clear Your Internet
Be sure to move your computer as close as you can to your WiFi router (the box that makes the WiFi.) Or better yet - plug your computer into the router with a cable!
After that, you'll want to close out of any programs you don't need which use your Internet connection. You may want to restart your computer.  For more information:

( Type Full Name )