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HIPAA NOTICE OF PRIVACY PRACTICES

I. 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.

II. It is my legal duty to safeguard your protected health information (PHI).

    By law I am required to insure that your PHI is kept private.  The PHI constitutes information created or noted by me that can be used to identify you.  It contains data about your past, present, or future health or condition, the provision of health care services to you, or the payment for such health care.  I am required to provide you with this notice about my privacy procedures. This notice must explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed when I release, transfer, give, or otherwise reveal it to a third party outside my practice. With some exceptions, I may not use or disclose more of your PHI than is necessary to accomplish the purpose for which the use or disclosure is made; however, I am always legally required to follow the privacy practices described in this notice.

Please note that I reserve the right to change the terms of this notice and my privacy policies at any time as permitted by law.  Any changes will apply to PHI already on file with me.  Before I make any important changes to my policies, I will immediately change this notice and post a new copy of it in my office and on my Web site. You may also request a copy of this notice from me, or you can view a copy of it in my office or on my Web site, which is located at www.drdyan.com.

I will also obtain an authorization from you before using or disclosing PHI in a way that is not described in this Notice.

III. How I will use and disclose your PHI.

I will use and disclose your PHI for many different reasons.  Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of my uses and disclosures, with some examples.

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Your Prior Written Consent

I may use and disclose your PHI without your consent for the following reasons:

1. For treatment:  I can use your PHI within my practice to provide you with mental health treatment, including discussing or sharing your PHI with my trainees and interns.  I may disclose your PHI to physicians, psychiatrists, psychologists, and other licensed health care providers who provide you with health care services or are otherwise involved in your care. Example: If a psychiatrist is treating you, I may disclose your PHI in order to coordinate your care.

2. For health care operations: I may disclose your PHI to facilitate the efficient and correct operation of my practice. Examples:  Quality control—I might use your PHI in the evaluation of the quality of health care services that you have received or to evaluate the performance of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys, accountants, consultants, and others to make sure that I am in compliance with applicable laws.

3. To obtain payment for treatment:  I may use and disclose your PHI to bill and collect payment for the treatment and services I provided you. Example: I might send your PHI to your insurance company or health plan in order to get payment for the health care services that I have provided to you. I could also provide your PHI to business associates, such as billing companies, claims processing companies, and others that process health care claims for my office.

4. Other disclosures:  Examples: Your consent isn’t required if you need emergency treatment provided that I attempt to get your consent after treatment is rendered. In the event that I try to get your consent but you are unable to communicate with me (for example, if you are unconscious or in severe pain) but I think that you would consent to such treatment if you could, I may disclose your PHI.

B. Certain Other Uses and Disclosures Do Not Require Your Consent

I may use and/or disclose your PHI without your consent or authorization for the following reasons:

1. When disclosure is required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement:  Example: I may make a disclosure to the appropriate officials when a law requires me to report information to government agencies, law enforcement personnel, and/or in an administrative proceeding.

2. If disclosure is compelled by a party to a proceeding before a court of an administrative agency pursuant to its lawful authority.

3. If disclosure is required by a search warrant lawfully issued to a governmental law enforcement agency.

4. If disclosure is compelled by the patient or the patient’s representative pursuant to your state's health and safety codes or to corresponding federal statutes of regulations, such as the privacy rule that requires this notice.

5. To avoid harm.  I may provide PHI to law enforcement personnel or persons able to prevent or mitigate a serious threat to the health or safety of a person or the public (i.e., adverse reaction to meds).

6. If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.

7. If disclosure is mandated by the your state's Child Abuse and Neglect Reporting law.  For example, if I have a reasonable suspicion of child abuse or neglect.

8. If disclosure is mandated by the your state's Elder/Dependent Adult Abuse Reporting law.  For example, if I have a reasonable suspicion of elder abuse or dependent adult abuse.

9. If disclosure is compelled or permitted by the fact that you tell me of a serious/ imminent threat of physical violence by you against a reasonably identifiable victim or victims.

10. For public health activities.  Example: In the event of your death, if a disclosure is permitted or compelled, I may need to give the county coroner information about you.

11. For health oversight activities. Example: I may be required to provide information to assist the government in the course of an investigation or inspection of a health care organization or provider.

12. For specific government functions.  Examples: I may disclose PHI of military personnel and veterans under certain circumstances. Also, I may disclose PHI in the interests of national security, such as protecting the president of the United States or assisting with intelligence operations.

13. For research purposes.  In certain circumstances, I may provide PHI in order to conduct medical research.

14. For Workers’ Compensation purposes.  I may provide PHI in order to comply with Workers’ Compensation laws.

15. Appointment reminders and health-related benefits or services.  Examples: I may use PHI to provide appointment reminders. I may use PHI to give you information about alternative treatment options or other health care services or benefits I offer.

16. If an arbitrator or arbitration panel compels disclosure,  when arbitration is lawfully requested by either party, pursuant to subpoena duces tectum (e.g., a subpoena for mental health records) or any other provision authorizing disclosure in a proceeding before an arbitrator or arbitration panel.

17. If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law.  Example: When compelled by U.S. Secretary of HHS to investigate or assess my compliance with HIPAA regulations.

18. If disclosure is otherwise specifically required by law.

19. When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the state’s confidentiality law. This includes certain narrowly-defined disclosures to law enforcement agencies, to a health oversight agency (such as HHS or a state department of health), to a coroner or medical examiner, for public health purposes relating to disease or FDA-regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.

C.  Certain Uses and Disclosures Require You to Have the Opportunity to Object

I may provide your PHI to a family member, friend, or other individual who you indicate is involved in your care or responsible for the payment for your health care, unless you object in whole or in part.  Retroactive consent may be obtained in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization

In any other situation not described in Sections IIIA, IIIB, and IIIC above, I will request your written authorization before using or disclosing any of your PHI. Even if you have signed an authorization to disclose your PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (assuming that I haven't taken any action subsequent to the original authorization) of your PHI by me.

IV. The rights you have regarding your PHI

A. The Right to See and Get Copies of Your PHI. 

In general, you have the right to see your PHI that is in my possession, or to get copies of it; however, you must request it in writing. If I do not have your PHI, but I know who does, I will advise you how you can get it. You will receive a response from me within 30 days of my receiving your written request. Under certain circumstances, I may feel I must deny your request, but if I do, I will give you, in writing, the reasons for the denial.  I will also explain your right to have my denial reviewed.

If you ask for copies of your PHI, I will charge you not more than $0.25 per page. I may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

B. The Right to Request Limits on Uses and Disclosures of Your PHI

You have the right to ask that I limit how I use and disclose your PHI. While I will consider your request, I am not legally bound to agree. If I do agree to your request, I will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that I am legally required or permitted to make.

C. The Right to Choose How I Send Your PHI to You

It is your right to ask that your PHI be sent to you at an alternate address (for example, sending information to your work address rather than your home address) or by an alternate method (for example, via e-mail instead of by regular mail). I am obliged to agree to your request providing that I can give you the PHI, in the format you requested, without undue inconvenience.  I may not require an explanation from you as to the basis of your request as a condition of providing communications on a confidential basis.

D. The Right to Get a List of the Disclosures I Have Made

You are entitled to a list of disclosures of your PHI that I have made. The list will not include uses or disclosures to which you have already consented, that is, those for treatment, payment, or health care operations, sent directly to you, or to your family; neither will the list include disclosures made for national security purposes, disclosures to corrections or law enforcement personnel, or disclosures made before April 15, 2003.  After April 15, 2003, disclosure records will be held for 6 years.

I will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list I give you will include disclosures made in the previous 6 years unless you indicate a shorter period. The list will include the date of the disclosure, to whom PHI was disclosed (including their address, if known), a description of the information disclosed, and the reason for the disclosure. I will provide the list to you at no cost, unless you make more than 1 request in the same year, in which case I will charge you a reasonable sum based on a set fee for each additional request.

E. The Right to Amend Your PHI

If you believe that there is some error in your PHI or that important information has been omitted, it is your right to request that I correct the existing information or add the missing information. Your request and the reason for the request must be made in writing. You will receive a response within 60 days of my receipt of your request. I may deny your request, in writing, if I find that: the PHI is (a) correct and complete, (b) forbidden to be disclosed, (c) not part of my records, or (d) written by someone other than me. My denial must be in writing and must state the reasons for the denial. It must also explain your right to file a written statement objecting to the denial. If you do not file a written objection, you still have the right to ask that your request and my denial be attached to any future disclosures of your PHI. If I approve your request, I will make the change(s) to your PHI. Additionally, I will tell you that the changes have been made, and I will advise all others who need to know about the change(s) to your PHI.

F. The Right to Get This Notice by E-mail

You have the right to get this notice by e-mail. You also have the right to request a paper copy of it.

G.  Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket. You have the right to restrict certain

disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.

H.  Right to Be Notified if There is a Breach of Your Unsecured PHI. You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

V. How to complain about my privacy practices

If, in your opinion, I may have violated your privacy rights, or if you object to a decision I made about access to your PHI, you are entitled to file a complaint with the person listed in Section VI below. You may also send a written complaint to the Secretary of the Department of Health and Human Services at 200 Independence Avenue S.W., Washington, D.C.  20201. If you file a complaint about my privacy practices, I will take no retaliatory action against you.

VI. Person to contact for information about this notice or to complain about my privacy practices

If you have any questions about this notice or any complaints about my privacy practices, or would like to know how to file a complaint with the Secretary of the DHHS, please contact me at: Dyan Haspel-Johnson, Ph.D, 201 Hunters Crossing Blvd, suite 10-245, Bastrop, TX  78602; 310-482-7917, dyan@drdyan.com.

VII. Effective date of this notice

This notice is in effect as of April 14, 2003.

Office Policies

This form provides you (patient) with information that is additional to that detailed in the Notice of Privacy Practices and it is subject to HIPAA pre-emptive analysis. (Revised 7/2021)

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 (client’s) written permission, except where disclosure is required by law.

When Disclosure Is Required By Law: Some of the circumstances where disclosure is required by the law are: where there is a reasonable suspicion of child, dependent or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled or when client’s family members communicate to Dr. Haspel-Johnson that the client presents a danger to others.

When Disclosure May Be Required: Disclosure may be required pursuant to a legal proceeding by or against you.  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 Dr. Haspel-Johnson. In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. Dr. Haspel-Johnson will use her clinical judgment when revealing such information. Dr. Haspel-Johnson will not release records to any outside party unless she is authorized to do so by all adult family members who were part of the treatment.

Emergencies: If there is an emergency during our work together, or in the future after termination where Dr. Haspel-Johnson becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, she will do whatever she 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, she may also contact the person whose name you 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.  Please note that Dr. Haspel-Johnson does not bill insurance companies directly but instead will provide you with an invoice called a superbill that you may submit to your insurance company for possible reimbursement. If you instruct Dr. Haspel-Johnson, only the minimum necessary information will be communicated to the carrier under necessary circumstances. Dr. Haspel-Johnson has no control or knowledge over what insurance companies do with the information she submits or who has access to this information.  You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job.  The risk stems from the fact that mental health information is likely to be entered into big insurance companies’ computers and is likely to be reported to the National Medical Data Bank.  Accessibility to companies’ computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to break in’s and unauthorized access.   Medical data has been also reported to be legally accessed by enforcement and other agencies, which also puts you in a vulnerable position.  Additionally, Dr. Haspel-Johnson maintains no responsibility for the amount or process of your insurance reimbursement, if any. It is the client’s responsibility to know the policies of their insurance with regards to mental health treatment and reimbursements.

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’s) nor your attorney’s, nor anyone else acting on your behalf will call on Dr. Haspel-Johnson to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

Consultation: Dr. Haspel-Johnson consults regularly with other professionals regarding her clients; however, client’s identity remains completely anonymous, and confidentiality is fully maintained.

E - Mails, Cell phones, Computers and Faxes: It is very important to be aware that computers and e-mail and cell phone communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication.   E-mails, in particular are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them.   Additionally, Dr. Haspel-Johnson’s e-mails are not encrypted.  Faxes can easily be sent erroneously to the wrong address. Dr. Haspel-Johnson’s computers are equipped with a firewall, a virus protection and a password and she also backs up all confidential information from her computers into external hard drives on a regular basis.  The external hard drives are stored securely off-site.  Please notify Dr. Haspel-Johnson if you decide to avoid or limit in any way the use of any or all communication devises, such as e-mail, cell-phone or Faxes.  If you communicate confidential or highly private information via e-mail or text, Dr. Haspel-Johnson will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and she will honor your desire to communicate on such matters via e-mail or text. Please do not use e-mail, text, or Faxes for emergencies. Dr. Haspel-Johnson does not regularly check emails, texts, or Faxes outside of business hours (8am to 5pm, Monday’s through Friday’s except for holidays or time off). If you need to reach Dr. Haspel-Johnson urgently outside of business hours, please call as she checks her voice mails more regularly and will return calls for urgent matters as soon as possible (unless she has a doctor on call for her). If you are experiencing a true emergency and can not reach Dr. Haspel-Johnson immediately, please call 9-1-1.

Records and Your Right to Review Them: Both the law and the standards of Dr. Haspel-Johnson’s profession require that she keeps appropriate treatment records for at least 7 years. Unless otherwise agreed to necessary Dr. Haspel-Johnson retains clinical records only as long as is mandated by California, Colorado or Texas law (depending on in which state you received treatment).  If you have concerns regarding the treatment records please discuss them with Dr. Haspel-Johnson.  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 Dr. Haspel-Johnson assesses that releasing such information might be harmful in any way.  In such a case Dr. Haspel-Johnson 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, Dr. Haspel-Johnson will release information to any agency/person you specify unless Dr. Haspel-Johnson assesses that releasing such information might be harmful in any way.   When more than one client involved in treatment, such as in cases of couple and family therapy, Dr. Haspel-Johnson will release records only with the signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment.

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact Dr. Haspel-Johnson between sessions, please leave a message on the voice mail (310) 482-7917 and your call will be returned as soon as possible, generally within 1 business day. Dr. Haspel-Johnson checks her messages a few times during the daytime only, unless she is out of town. Please be aware that Dr. Haspel-Johnson generally does not check or respond to emails, faxes, texts or voicemails that are of a non-urgent nature outside of business hours (business hours are normally Monday through Friday 8am-5pm). If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call your local County Dept of Mental Health Psychiatric Emergency 24-hour Crisis Hotline: (800)854-7771, National Hopeline Network 24-hour crisis line: (800)784-2433, or the Police: 911.  Please do not use e-mail or Faxes for emergencies. Again, Dr. Haspel-Johnson does not always check her e-mail or Faxes daily.

PAYMENTS & INSURANCE REIMBURSEMENT: Clients are expected to pay the standard fee of $500 per 50 minute per hour session at the end of each session or at the end of the month unless other arrangements have been made.  Telephone conversations, site visits, report writing and reading, consultation with other professionals, release of information, reading records, longer sessions, travel time, and text and email correspondences etc. will be charged at the same rate, unless indicated and agreed upon otherwise. If you need to contact Dr. Haspel-Johnson to discuss something via email, telephone, text, or other communication, please note that there will be no charge for correspondences taking 10 minutes or less. If communications are frequent or take more time than 10 minutes, the time will be billed accordingly. Please notify Dr. Haspel-Johnson if any problems arise during the course of therapy regarding your ability to make timely payments.  Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies.  Unless agreed upon differently, Dr. Haspel-Johnson will provide you with a copy of your receipt on a monthly basis at your request only, which you can then submit to your insurance company for reimbursement if you so choose.  As was indicated in the section Health Insurance & confidentiality of records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk.  Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies.  It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, Dr. Haspel-Johnson can use legal or other means (courts, collection agencies, etc.) to obtain payment.

MEDIATION & ARBITRATION: All disputes arising out of or in relation to this agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration.  The mediator shall be a neutral third party chosen by agreement of Dr. Haspel-Johnson and client(s).  The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon.  In the event that mediation is unsuccessful, any unresolved controversy related to this agreement should be submitted to and settled by binding arbitration in Bastrop, TX in accordance with the rules of the American Arbitration Association which are in effect at the time the demand for arbitration is filed.   Notwithstanding the foregoing, in the event that your account is overdue (unpaid) and there is no agreement on a payment plan, Dr. Haspel-Johnson can use legal means (court, collection agency, etc.) to obtain payment.   The prevailing party in arbitration or collection proceeding shall be entitled to recover a reasonable sum as and for attorneys’ fees.  In the case of arbitration, the arbitrator will determine that sum.

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy.  Working toward these benefits, however, requires effort on your part.  Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings and/or behavior. Dr. Haspel-Johnson will ask for your feedback and views on your therapy, it’s progress and other aspects of the therapy and will expect you to respond openly and honestly.  Sometimes more than one approach can be helpful in dealing with a certain situation.  During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc, or experiencing anxiety, depression, insomnia, etc. Dr. Haspel-Johnson may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel very upset, angry, depressed, challenged or disappointed.  Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships may result in changes that were not originally intended.  Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing or relationships.  Sometimes a decision that is positive for one family member is viewed quite negatively by another family member.  Change will sometimes be easy and swift, but more often it will be slow and even frustrating.  There is no guarantee that psychotherapy will yield positive or intended results. During the course of therapy, Dr. Haspel-Johnson is likely to draw on various psychological approaches according, in part, to the problem that is being treated and her assessment of what will best benefit you.  These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, existential, system/family, developmental (adult, child, family), humanistic or psycho-educational. Dr. Haspel-Johnson may also incorporate non-sexual touch as part of psychotherapy. Sexual touch of clients by therapists is unethical and illegal. Dr. Haspel-Johnson will ask your permission before touching you, and you have the right to decline or refuse to be touched without any fear or concern about reprisal. Touch can be very beneficial but can also unexpectedly evoke emotions, thoughts, physical reactions or memories that may be upsetting, depressing, evoke anger, etc. Sharing and processing such feelings with the therapist, if they arise, may be a helpful part of therapy. You may request not to be touched at any time during therapy without needing to explain it, if you choose not to, and without fear of punishment. Dr. Haspel-Johnson provides neither custody evaluation recommendation nor medication or prescription recommendation nor legal advice, as these activities do not fall within her scope of practice.

Discussion of Treatment Plan: Within a reasonable period of time after the initiation of treatment, Dr. Haspel-Johnson will discuss with you (client) her working understanding of the problem, treatment plan, therapeutic objectives and 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, Dr. Haspel-Johnson’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.  If you could benefit from any treatment that Dr. Haspel-Johnson does not provide, she has an ethical obligation to assist you in obtaining those treatments.

Termination:  As set forth above, after the first couple of meetings, Dr. Haspel-Johnson will assess if she can be of benefit to you. Dr. Haspel-Johnson does not accept clients who, in her opinion, she cannot help.  In such a case, she will give you a number of referrals who you can contact.  If at any point during psychotherapy Dr. Haspel-Johnson assesses that she is not effective in helping you reach the therapeutic goals or that you are non-compliant she is obligated to discuss it with you and, if appropriate, to terminate treatment.  In such a case, she would give you a number of referrals that may be of help to you.  If you request it and authorize it in writing, Dr. Haspel-Johnson 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, Dr. Haspel-Johnson will assist you with referrals, and if she has your written consent, she 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, if appropriate, Dr. Haspel-Johnson will offer to provide you with names of other qualified professionals.

DUAL RELATIONSHIPS: Not all dual or multiple relationships are unethical or avoidable.  Therapy never involves sexual or any other dual relationship that impairs Dr. Haspel-Johnson’s objectivity, clinical judgment or can be exploitative in nature. Dr. Haspel-Johnson will assess carefully before entering into non-sexual and non-exploitative dual relationships with clients.  Within each community there can be circumstances unrelated to therapy where clients may happen to know each other and Dr. Haspel-Johnson from the community.  Consequently you may bump into Dr. Haspel-Johnson out in the community, or may discover that you know another client of Dr. Haspel-Johnson's. Note that Dr. Haspel-Johnson will never acknowledge working with anyone without his/her/their written permission. Further, if she sees you out in the community, she will follow your lead in terms of acknowledging that you know each other.  Many clients choose Dr. Haspel-Johnson as their therapist because they know her before they enter into therapy with her and/or are personally aware of her professional work and achievements.  Nevertheless, Dr. Haspel-Johnson will discuss with you the often-existing complexities, potential benefits and difficulties that may be involved in dual or multiple relationships.  Dual or multiple relationships can enhance trust and therapeutic effectiveness but can also detract from it and often it is impossible to know that ahead of time.  It is your, the client’s responsibility to communicate to Dr. Haspel-Johnson if the dual or multiple relationship become uncomfortable for you in any way. Dr. Haspel-Johnson will always listen carefully and respond accordingly to your feedback and will discontinue the dual relationship if she finds it interfering with the effectiveness of the therapy or the welfare of the client and of course you can do the same at any time.

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 24 business day hours (1 business day’s) notice is required for re-scheduling or canceling an appointment. Please note that 1 (one) business day means that if you have an appointment on a Monday at 10am, for example, you must let Dr. Haspel-Johnson know if you need to cancel by 10am the previous Friday.  Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification.  Most insurance companies do not reimburse for missed sessions. Therefore, you, the client, will be charged the full fee for those appointments regardless of whether or not insurance will reimburse you; a superbill cannot be provided for missed or canceled sessions.

Telemedicine Consent

I consent to engage in telemedicine (e.g., internet or telephone based therapy) with Dr. Dyan Haspel-Johnson, Ph.D. as the main venue for my psychotherapy treatment. I understand that “telemedicine” includes the practice of health care delivery, including mental health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, and/or data communications. I understand that telemedicine also involves the communication of my medical/mental health information, both orally and visually, to other health care practitioners located in or outside of the state where I reside.

I understand that I have the following rights with respect to telemedicine:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to: reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. (See also Office Policies and HIPAA Notice of Privacy Practices forms for more details of confidentiality and other issues).

I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from telemedicine. These may include, but are not limited to, the possibility, despite reasonable efforts on the part of my psychotherapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; the electronic storage of my medical information could be accessed by unauthorized persons and/or misunderstandings can more easily occur, especially when care is delivered in an asynchronous manner.

In addition, I understand that telemedicine based services and care differ in certain ways from face-to-face services and may not yield the exact same results nor be experienced in the exact same way. I also understand that if my psychotherapist believes I would be better served by another form of psychotherapeutic service (e.g. face-to-face service) I will be referred to a psychotherapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite my efforts and the efforts of my psychotherapist, my condition may not be improve, and in some cases, at least temporarily, certain symptoms may even get worse.

(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured. The benefits of telemedicine may include but are not limited to: finding a greater ability to express thoughts and emotions; transportation and travel difficulties are avoided; time constraints are minimized; and there may be a greater opportunity to prepare in advance for therapy sessions.

(5) I understand that I have the right to access my medical information and copies of medical records in accordance with the state law where I reside, that these services may not be covered by insurance and that if there is intentional misrepresentation, therapy will be terminated.

I have read and understand the information provided above. I have discussed it with my psychotherapist, and all of my questions have been answered to my satisfaction.