Telemental health is the practice of delivering clinical health care services via technology assisted media or other electronic means between a practitioner and a client who are located in two different locations.

I understand the following with respect to telemental health:

1) I understand that a telehealth consultation/visit has potential benefits including easier access to care and convenience of meeting from a location of my choosing.

2) I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand that my healthcare provider or I can discontinue the telehealth consult/visit if is felt that the connections are not adequate for the situation.

3) I understand that except where otherwise noted, my provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting my privacy and ensuring that records of my health care services are not lost or damaged.

4) I understand that I may not record video or audio sessions without my providers consent and doing so may be a violation of state privacy laws. My provider with not record video or audio sessions.

5) I understand that to ensure my safety during mental health crises, medical emergencies and sessions I will designate an emergency contact for my provider.

6) I have had a direct conversation with my provider, during which I had the opportunity to ask questions in regard to this procedure. My questions have been answered and the risks, benefits and any practical alternative have been discussed with me in a language in which I understand.

7) I understand that my provider can only conduct telemental health sessions with me when I am physically located in a state in which they are licensed. I agree that I will not misrepresent my location to my provider at the time of our appointments and will release and hold harmless my provider of any liabilities should I misrepresent my physical location.

By signing this form, I certify:

 - That I have read or had this form read and/or had this form explained to me.

 - That I fully understand its contents including the risks and benefits of the procedure(s).

 - That I have been given amply opportunity to ask questions and that any questions have been answered to my satisfaction.

 - By signing below, I am agreeing that I have read, understood and agree to the items contained in this document.

I, (patient or Guardian) herby consent to engaging in telemental Health with my therapist at Kimberly Orth LCSW, PC as part of my psychotherapy. I understand that "telehealth" includes the practice of health care delivery, diagnosis, consultation, treatment using interactive audio-video communications. I also understand that, with my signed consent, telemedicine may involve the electronic communication of my medical/mental healthcare information to other health care practitioners. The rights states supplement those rights I have generally as a patient of the psychotherapist.

THERAPIST-CLIENT SERVICE AGREEMENT
Welcome to Kimberly Orth LCSW, PC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPPA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have.

INTAKE PROCESS
The initial session begins with a review of the detailed intake history you have filled out prior to your session. Together, we will go over the forms and provide a space for you to voice your concerns and personal goals for seeking treatment. If additional services are recommended that I cannot provide, I will provide you with appropriate referrals. Throughout any time in your therapy process, it is within your power to decide if the treatment process is suitable for you. If you should wish to seek alternate care I would be happy to review and/or provide you with a referral source as necessary.

PSYCHOLOGICAL SERVICES
Psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, such as sadness, guilt, anxiety, anger, frustration, loneliness and helplessness, because the process of psychotherapy often requires discussing the unpleasant aspects of life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems. It is important to understand that therapy is an interactive process and that your participation as "the client" is imperative. Therapy equips you with the necessary told (or coping skills) needed to better manage stress and symptoms on your own. Whereas medication targets symptoms, therapy targets the cause, triggers and symptoms. Together we will identify the behaviors, relationship patterns and/or cognitions that stagnate your progress so that you can begin to move forward and gain a better understanding of yourself.

APPOINTMENTS
Sessions will ordinarily be 45-60 minutes in duration, once per week at a time we agree upon. The time scheduled for your appointment is assigned to you and you alone. If you need to cancel or reschedule a session I ask that you provide 24-48 hours notice. If you miss a session without cancelling or cancel with less than 24 hour notice, my policy is to collect a cancellation fee of $50. Insurance companies do not provide reimbursement for cancelled sessions, thus, you will be responsible for the fee as described above. If it is possible, I will try to find a time to reschedule an appointment with notice. Kimberly Orth, LCSW PC reserves the right to discharge a client from practice for 2 No-Shows/Late cancellations in a 6 month period.

PROFESSIONAL FEES
Fees are due in full at time the service is rendered. Individual sessions are 45-60 minutes long and the fee is $150. There may be additional charges for coordinating care with another entity (doctor, school, probation, parents of minors, attorney, etc.). In the event I am asked to attend a meeting, hearing, court date or other appointment outside of the office the full rate of $300 per hour will be charged. Any checks returned to the office are subject to an additional fee of up to $25.00 to cover bank fee that I incur.If you refuse to pay your debt I reserve the right to use an attorney or collection agency to secure payment. The client is encouraged to speak openly with the therapist if payment of the fee is difficult financially. I believe financial concerns should not be a barrier to clients seeking treatment; therefore I have allotted several "sliding scale" slots in my practice for lower rates (based on income/W2 required).

INSURANCE
If you have a health insurance policy; it will usually provide some coverage for mental health treatment. With your permission, I will assist you to the extent possible in filing claims and ascertaining information about your coverage. You are responsible for knowing your coverage and for advising me of any coverage changes.

Managed Health Care plans such as HMOs and PPOs often require advance authorization. These plans are often limited to short-term treatment approaches and it may be necessary to seek approval for more therapy after a certain number of sessions. Some managed care plans will not allow me to provide services to you once your benefits end. If this is the care I will do my best to find another provider who will help you continue your psychotherapy.

Most insurance companies require you to authorize me to provide them with a clinical diagnosis, pr additional clinical information such as treatment plans or summaries. I will provide you with any report I submit upon your request. By signing this Agreement, you agree that I can provide requested information to your carrier if you plan to pay with insurance.

In addition, if you plan to use your insurance and authorization is required you must obtain prior to service or you will be responsible for full payment of the fee. Many policies leave a percentage of the fee (Co-insurance) or a flat dollar amount (co-payment) to be covered by the patient. This amount will be paid at time of visit by credit card or check. Some insurance companies have a deductible. If yours does, you will be responsible to pay for initial sessions with me until your deductible has been met. Deductible amounts may also need to be met at the start of each calendar year. If I am not a participating provider of your insurance plan, I will supply you with a receipt of payment for services, which you can submit to your insurance company for reimbursement. Please not that not all insurance companies reimburse for out-of-network providers.

PROFESSIONAL RECORDS
Both law and the ethical standards of my profession require that I keep appropriate treatment records. They are kept in a safe, HIPPA compliant electronic record. If you wish to see your records, I recommend that you review them with me as professional records may be misinterpreted to untrained readers. You have a right to request that a copy of your file be made available to any other health care provider at your written request. All records request must be submitted in writing with appropriate Release of information signed and with 5 business days advance notice.

PARENTS AND MINORS
It is my policy not to provide treatment to a child under age 13 unless s/he agrees that I can share whatever information I consider necessary with a parent. For children 14 and older, I request an agreement between the client and parents allowing me to share general information about treatment progress and attendance, as well as a treatment summary upon completion of therapy. All other communication will require child's agreement, unless I feel there is a safety concern, in which case I will make every effort to notify the child of my intention to disclose information ahead of time and make every effort to handle an objections that are raised.

CONTACTING ME
I am often not immediately available by telephone. At these times, you may leave a message on my confidential voice mail and your call will be returned as soon as possible, but it may take a day or two for non-urgent matters. If it's a life threatening emergency please access additional resources to keep yourself safe, 1) go to your local hospital emergency room, or 2) call 911 and ask to speak with a mental health professional.

CONSENT TO PSYCHOTHERAPY
Your signature below indicated that you have read this Agreement and the Notice of Privacy Practices and agree to their terms.

Notice Of Privacy Practices
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

This notice describes how health information about you (as a patient of this practice) may be used and disclosed and how you can get access to your individually identifiable health information.

Please review this notice carefully.

A. Our commitment to your privacy: Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:
- How we may use and disclose your PHI,
- Your privacy rights in your PHI,
- Our obligations concerning the use and disclosure of your PHI.

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.

B. If you have questions about this Notice, please contact:

Kimberly Orth, LCSW PO BOX 174 St. James NY 11780

C. We may use and disclose your PHI in the following ways:
The following categories describe the different ways in which we may use and disclose your PHI.
1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice - including, but not limited to, our doctors and nurses - may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other health care providers for purposes related to your treatment.

2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health care providers and entities to assist in their billing and collection efforts.

3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations.

4. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.

D. Use and disclosure of your PHI in certain special circumstances:
The following categories describe unique scenarios in which we may use or disclose your identifiable health information:
1. Public health risks. Our practice may disclose your PHI to public health authorities that are authorized by law to collect information for the purpose of:
- Maintaining vital records, such as births and deaths,
- Reporting child abuse or neglect,
- Preventing or controlling disease, injury or disability,
- Notifying a person regarding potential exposure to a communicable disease,
- Notifying a person regarding a potential risk for spreading or contracting a disease or condition,
- Reporting reactions to drugs or problems with products or devices,
- Notifying individuals if a product or device they may be using has been recalled,
- Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information,
- Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.

2. Health oversight activities. Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

3. Lawsuits and similar proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your PHI in response to a discovery request, subpoena or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law enforcement. We may release PHI if asked to do so by a law enforcement official:
- Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement,
- Concerning a death we believe has resulted from criminal conduct,
- Regarding criminal conduct at our offices,
- In response to a warrant, summons, court order, subpoena or similar legal process,
- To identify/locate a suspect, material witness, fugitive or missing person,
- In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator).

(A) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (i) an adequate plan to protect the identifiers from improper use and disclosure; (ii) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (iii) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted;
(B) The research could not practicably be conducted without the waiver,
(C) The research could not practicably be conducted without access to and use of the PHI.

8. Serious threats to health or safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

9. Military. Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

10. National security. Our practice may disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.

11. Inmates. Our practice may disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

12. Workers' compensation. Our practice may release your PHI for workers' compensation and similar programs.

E. Your rights regarding your PHI:
You have the following rights regarding the PHI that we maintain about you:

1. Confidential communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than work. In order to request a type of confidential communication, you must make a written request to Kimberly Orth, LCSW specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to Kimberly Orth, LCSW Your request must describe in a clear and concise fashion:
- The information you wish restricted,
- Whether you are requesting to limit our practice's use, disclosure or both,
- To whom you want the limits to apply.

3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to Kimberly Orth, LCSW in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted to Kimberly Orth, LCSW. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of disclosures. All of our patients have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented - for example, the doctor sharing information with the nurse; or the billing department using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to Kimberly Orth LCSW, P.C. All requests for an "accounting of disclosures" must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact Kimberly Orth, LCSW.

7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact Kimberly Orth, LCSW. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to provide an authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note: we are required to retain records of your care.

Again, if you have any questions regarding this notice or our health information privacy policies, please contact Kimberly Orth, LCSW PO BOX 174 St. James NY 11780

Copyright 2002 Gates, Moore & Company. Used with permission. "The HIPAA Privacy Rule: Three Key Forms." Bush J. Family Practice Management. February 2003:29-33, http://www.aafp.org/fpm/20030200/29theh.htm