INFORMED CONSENT

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This notice contains important information about our professional services, business policies, and how the Advanced Psychology Institute handles your personal information. In addition, it contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protection and protects patient rights with regard to the use of disclosure of your Protected Health Information (PHI), used for the purpose of evaluation, treatment, payment, and health care operations.

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The law protects the privacy of all communications between a patient and a psychologist. In most situations we can only release information about your evaluation or treatment to others if you sign a written authorization form that meets certain legal requirements imposed by state law or HIPAA. Patients who are 14 or older must sign the written authorization form. The law requires that the Advanced Psychology Institute obtains your signature acknowledging that the Advanced Psychology Institute has provided you with this information. When you sign this document, it will represent an Agreement between us.

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You may revoke this Agreement at any time. That revocation will be binding on us unless there are obligations imposed on us by your health insurer in order to process or substantiate claims made under your policy, or if you have not satisfied any financial obligations you have incurred.

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PSYCHOLOGICAL SERVICES

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Our psychological services include psychological assessment, consultations and psychotherapy. Currently, all our services are provided via video conferencing.

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The goal of assessment is to understand your presenting problem and to recommend to you one of our or affiliated providers whose expertise is most suitable for your specific issues.

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Consultation usually includes looking for understanding and solutions to your presenting problem including emotional, interpersonal and communication issues. We provide consultations for individuals, couples, and families.

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Psychotherapy deals with your mental health issues that include depression and anxiety among many other possible conditions. There are many different methods the Advanced Psychology Institute may offer to deal with problems that you hope to address. Unlike a medical doctor visit, psychotherapy typically requires a very active effort on your part. Since many mental health issues are caused or triggered by interpersonal relationship difficulties, therapy often includes counseling.

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Since therapy may involve discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness or helplessness. On the other hand, psychotherapy has also been shown to benefit people who go through it. Therapy, alone or in combination with other means – {medications, TMS, etc. – generally leads to better functioning, solutions to specific problems, and significant reductions in feelings of distress. However, one cannot predict how these experiences will unfold, or how intense these experiences will be for you.

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Counseling and therapy involve a large commitment of time and energy, as well as a financial commitment. The Advanced Psychology Institute will be happy to answer all your questions and will always respect your right to stop working with us at any time and for any reason.

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COMMUNICATION

For any administrative questions such as rescheduling or canceling appointments, you can reach us by leaving a voicemail at or sending a text message to our main number, or by email. If you need to communicate with a specific person, please provide their name in your message. Please be aware that such communications are not secure and confidential by their nature and therefore should not contain any personal or sensitive information.

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If you need a response, all efforts will be made to answer your request within 24 hours, with the exception of weekends and holidays. If you are difficult to reach on the phone, please inform us of times when you will be available or provide alternative ways to communicate with you such as email or text messages.

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If you feel that you cannot wait for us to return your call or message, please contact your primary physician or go to the nearest emergency room.

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PROFESSIONAL FEES

Our fees vary depending on the services provided. We guarantee that all fees will be disclosed to you before you commit to treatment and no hidden or unexpected fees will ever be charged. The fees are subject to change at any time and you will be notified thirty (30) days in advance of this change.

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Patients with low income or in financial hardship have an option to apply for financial help provided by The Fradkov Mental Health Financial Aid Program. The applications will be considered on an individual basis and if the aid is granted, it will reduce the amount of your payments.

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BILLING AND PAYMENTS

We expect full payment at the end of every session. At the end of each month you will be presented with a written statement of services provided, which includes dates of your sessions and amount paid. Please keep track of your sessions, as errors are always possible. Please bring any discrepancies to our attention for review.

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Our statements are valid to be presented to your health insurance, and if your policy covers out-of-network mental health treatment, it may partially reimburse you. The Advanced Psychology Institute will provide whatever assistance we can to help you receive benefits to which you are entitled. However, it is you – not your insurance company – who is responsible for the payment in full.

If your account has not been paid for more than 30 days and arrangements for payment have not been agreed upon, the Advanced Psychology Institute has the option of using legal means to secure payment. This may involve hiring a collection agency or filing an action in small claims court. In most collection situations, the only information the Advanced Psychology Institute releases regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due.

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CANCELLATION POLICY

Our cancellation policy is in place to ensure that we can offer timely psychological support to all our clients. We appreciate your understanding and cooperation.

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24-Hour Notice: If you need to cancel or reschedule your appointment, please notify us at least 24 hours in advance and we will offer you a make-up appointment typically within the next 2 weeks. This allows us to allocate your reserved time to another patient in need of our services.

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Late Cancellations and No-Shows: If you cancel your appointment in less than 24 hours before the scheduled appointment or miss your appointment without a prior notification, you will be responsible for the full cost of the session to cover the reserved time and resources. Please note that insurance companies typically do not provide reimbursement for canceled or missed sessions.

We understand that certain force majeure situations may prevent you from informing us in advance. In such cases, please contact us as soon as possible to discuss the circumstances.

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Fee Waiver for Emergencies: We understand that certain force majeure situations may prevent you from informing us in advance. In such cases, please contact us as soon as possible to discuss the circumstances. If you are unable to meet the 24-hour notice requirement due to a genuine emergency, such as a serious illness or a family or work-related emergency, we may be able to waive the cancellation fee on a case-by-case basis.

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Vacations: We will provide you with a two-week notice if your provider is having a vacation. We expect a similar courtesy from you.

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PROFESSIONAL RECORDS

The laws and standards of our profession require us to keep Protected Health Information about you in your Clinical Record. It is likely to include the following:

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• Your personal history
• Reasons you came for treatment: problems, symptoms, needs, goals
• Diagnoses: medical terms for your problems, symptoms, disabilities
• Treatment Plan: services that your provider at the Advanced Psychology Institute thinks will help you
• Progress Notes
• Records from others who treated or evaluated you
• Information about medications you are taking
• Legal matters

Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to us confidentially by others, you may request a review of your Clinical Record (electronic or paper, depending on the way information was stored). Such a request should be made in writing. Because these are professional records, they can be misinterpreted to untrained readers. For this reason, the Advanced Psychology Institute requires that you review them in your provider’s presence so that you can discuss and clarify the contents. If the Advanced Psychology Institute provider refuses your request for access to your records, you have a right of review, which the Advanced Psychology Institute will discuss with you upon request.

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PATIENTS RIGHTS

HIPAA provides you with expanded rights with regard to your Clinical Records and disclosures of Protected Health Information (PHI). These rights include requesting that the Advanced Psychology Institute amends your record, requesting restrictions on what information from your Clinical Record is supplied to others, requesting an accounting of most disclosures of Protected Health Information that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent, having any complaints you make about our policies and procedures recorded in your records, and the right to a paper copy or electronic copy of this Agreement, the included Notice Form, and our privacy policies and procedures.

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In addition, you have the right to equal consideration and treatment regardless of your sex, age, race, religion, color, economic status, or sexual preference. You have the right to know your provider’s assessment of your problem, the recommended treatment plan, and resources available to help improve this problem. You also have the right to refuse treatment, which means that even though the Advanced Psychology Institute may strongly suggest that you seek help, you may choose to not follow our expert’s advice. Should you choose to refuse treatment, you will be advised of the consequences that may result from your refusal. Alternative forms of treatment or help may be available. The Advanced Psychology Institute is happy to discuss all of the above-mentioned rights with you.

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LIMITS ON CONFIDENTIALITY

When your information is read by your provider at the Advanced Psychology Institute or other professionals related to your treatment, it is called “use.” If the information is shared with or sent to others outside this office, it is called “disclosure.” Except in some special circumstances, when the Advanced Psychology Institute uses your PHI or discloses it to others, the Advanced Psychology Institute will share only the minimum necessary PHI needed for the purpose. The law gives you rights to know about your PHI, how it is used, and to have a say in how it is disclosed. The law protects the privacy of all communication between a patient and a provider. In most situations, the Advanced Psychology Institute cannot release information about our work to others unless you sign an Authorization Form that meets clear legal requirements imposed by HIPAA. There are other situations that require your advanced written consent. Your signature on this Agreement provides consent for those activities, as follows:

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• The Advanced Psychology Institute may occasionally find it helpful to consult with other professionals about your case. During a consultation, the Advanced Psychology Institute makes every effort to conceal your identity. Other professionals are also legally bound to keep this information confidential. The Advanced Psychology Institute will note all consultations in your Clinical Record.
• We, at the Advanced Psychology Institute, are a treatment team of mental health professionals who play various roles in serving your mental health needs. Your provider at The Advanced Psychology Institute may consult with other members of the treatment team regarding varied details of your case. Each treatment team member is bound by the same confidentiality rules.
• Disclosures required by health insurers, or to collect overdue fees are disclosed elsewhere in this Agreement.
• If our provider indicates that you present danger to yourself or others, the Advanced Psychology Institute may be obligated to seek hospitalization for you, and/or to contact family members, and/or anyone else who can help provide protection.

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There are some situations in which the Advanced Psychology Institute is permitted or required to disclose information without either your consent or Authorization:

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• If you are involved in a court proceeding and a request is made for information concerning the professional services that the Advanced Psychology Institute provided, or provides for you, such information is protected by the psychologist-patient privilege law. The Advanced Psychology Institute cannot provide any information without your written authorization, or court order. If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order the Institute to disclose information.
• If a government agency is requesting the information for health oversight activities, the Advanced Psychology Institute may be required to provide this information.
• If you file a complaint or lawsuit against the Advanced Psychology Institute or one of its providers, the Advanced Psychology Institute may disclose any relevant information in order to defendvthemselves.
• If the Advanced Psychology Institute is providing treatment for conditions directly related to a Worker’s Compensation claim, the Advanced Psychology Institute may have to submit such records, upon appropriate request, to the Chairman of the Worker’s Compensation Board on such forms and at such times as the chairman may require.

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Unless you instruct us not to, the Advanced Psychology Institute may contact you or leave messages on your voicemail to remind you of appointments and to offer information about referrals and treatment alternatives.

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• The Advanced Psychology Institute has to disclose information necessary to enable a patient to apply for or receive benefits when that person is not capable of consenting or is not available to do so.
• The Advanced Psychology Institute may have to disclose your PHI to a supervising consulting therapist, members of your treatment team, or an attorney consultant. The members of your treatment team may include another psychologist, psychiatrist, mental health counselor, health coach, or a social worker who are associates of or affiliated with the Advanced Psychology Institute and who are directly involved in providing care and services for you
• The Advanced Psychology Institute may have to disclose to an officer of the law or prosecuting attorney conducting an investigation of a criminal offense, or attempting to apprehend a fugitive, in which case the Advanced Psychology Institute may disclose whether a person is present at our office or office building. The police must present a case number and the purpose of the investigation or an outstanding arrest warrant.
• The Advanced Psychology Institute may have to disclose your PHI to the Office of the Inspector General for the Department of Children and Family Services in cases in which the patient is an alleged perpetrator of abuse or neglect, the subject of an abuse or neglect

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There are some situations in which the Advanced Psychology Institute team is legally obligated to take actions which we believe are necessary to protect others from harm including revealing some information about your treatment. These situations, which are highly unusual in our practice, include:

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• If, in your provider’s professional capacity, the Advanced Psychology Institute receives information from a child or the parents, guardian or other custodian of a child that gives us a reasonable cause to suspect that a child is being abused or neglected, the law requires that the Advanced Psychology Institutereport to the appropriate governmental agency, usually to the statewide central register of child abuse and maltreatment, or to the local child protective services office. Once such a report is filed, the Advanced Psychology Institute may be required to provide additional information.
• If you communicate the intention or convey plausible likelihood to act on an immediate threat of serious physical harm to an identifiable victim(s), then a Duty to Warn and Protect will be legally incurred by the Advanced Psychology Institute on behalf of your healthcare clinician, and the Advanced Psychology Institute will be required to take protective actions. These actions include but may not be limited to:
  • notifying the potential victim about the prospective danger;
  • seeking voluntary or involuntary psychiatric hospitalization for the patient;
  • contacting the Chief of Police or acting officer in this capacity in the jurisdiction(s) where the intended victim and patient resides for the purpose of protecting the victim and conducting a firearms check.

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If any of such situations arises, we will make every effort to fully discuss it with you before taking any action and will limit the disclosure only to nonclinical information.

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Timely written permission: In the event that an urgent but non-life-threatening situation requires your provider’s correspondence with another party, the Advanced Psychology Institute may use or disclose your information with parties that are directly involved in your treatment with your electronic written permission, such as by email or fax.

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Treatment Team Information Sharing: Within the Advanced Psychology Institute, several professionals may form your treatment team. For example, a psychologist, a health coach, or a psychiatrist can be involved in your care. In order to provide best possible support, pertinent information will be shared among professionals that are involved in your care.

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YOUR RIGHTS REGARDING YOUR PHI:

You have the following rights regarding PHI that the Advanced Psychology Institute maintains about you. To exercise any of these rights, please submit your request in writing to: Valery Fradkov at 440 West Street, Suite 323, Fort Lee, New Jersey 07024:

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• Right of Access to Inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that may be used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you. The Advanced Psychology Institute may charge a reasonable, cost-based fee for copies.
• Right to Amend. If you feel that the PHI that The Advanced Psychology Institute has about you is incorrect or incomplete, you may ask her to amend the information, although The Advanced Psychology Institute is not required to agree to the amendment.
• Right to an Accounting of Disclosures. You have the right to request an accounting of certain of the disclosures that The Advanced Psychology Institute makes of your PHI. The Advanced Psychology Institute may charge you a reasonable fee if you request more than one accounting in any 12-month period.
• Right to Request Restrictions. You have the right to request a restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. The Advanced Psychology Institute is not required to agree to your request. The Advanced Psychology Institute, however, is required to comply with your request if it relates to a disclosure to your health plan regarding health care items or services for which you have paid the bill in full.
• Right to Request Confidential Communication. You have the right to request that The Advanced Psychology Institute communicates with you about medical matters in a certain way or at a certain location.
• Right to a Copy of this Notice. You have a right to a copy of this notice.

If you have a problem with how your PHI has been handled, or if you believe your privacy rights have been violated, please let us know. You have the right to file a complaint with us and with the Secretary of the Federal Department of Health and Human Services. The Advanced Psychology Institute will not in any way limit your care or take any actions against you if you complain. Valery Fradkov is the designated privacy officer for The Advanced Psychology Institute, and he can be reached by phone at (201) 497-0289 via voice or text.

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