Chapter 3: Client Forms

Financial Arrangements

There are a couple of potential ways for a client to pay for mental health services:

• Personal Health Insurance: Insurance policies vary widely in the amount and type of mental health care they will cover. The client will need to know about their particular policy. There are a number of questions they should ask their insurance company. Before they make an appointment they should ask:
  • Will the policy pay for mental health services in the city and state the agency is located in?
  • Which mental health services are covered by my policy?
  • Can I see the provider of my choice or must I choose from a "preferred list of providers"?
  • What happens if I want to see someone not on that list?
  • Is there an annual limit on the number of counseling sessions covered?
  • Does my plan exclude certain diagnoses or pre-existing conditions?
  • Will the company pay for the services I need? If so, will they pay the entire cost?
    • If not, what costs are not covered?
    • Is there a co-pay?
    • Is there a deductable?
    • What is the amount of my plan's "usual, customary, and reasonable (UCR)" coverage?
    • Does fee of the therapist at the agency I want to go to ($___) meet the UCR coverage?
  • Do I need a pre-certification, prior authorization, or referral from my primary care provider?


If the answers to those questions are satisfactory, then the client should ask the company representative:
• Sliding Scale Fee. Community mental health services (and sometimes other services) often offer a sliding scale option. Clients who must pay from their own funds because they have no insurance or because their insurance does not cover the treatment they need may be able to work out a sliding fee scale from your agency. The agency will then charge the client according to what he can afford based on the financial condition and household income.

No matter which form of payment is agreed upon, the exact agreement must be in writing and signed. A signed copy of this agreement is part of the client's record.

HIPAA and Limits of Confidentiality

It has already been mentioned that a HIPPA "Notice of Privacy Practices" must be signed by the client, indicating their receipt of that notice. The notice likely will give a list of patients' rights under that law. As with any law, changes may be made over time, but in 2011 these rights included:

• The right to receive the Required Notice of Privacy Practices--Discussed earlier.
• The right to request restriction on the uses and disclosures of protected health information (PHI)--The agency must give the client an opportunity to ask for restrictions of uses and disclosures of the PHI for treatment, payment, and operations, and to family, friends, and other involved in their care. However, the agency is not required to agree to the request, but will abide by it if they do agree, except in an emergency. If the restricted PHI is given to a provider for treatment in an emergency, that provider will be requested to not use further or discover the information.
• The right to request confidential communications--The client may ask the mental health agency to give them the communications from their protected health information with no explanation of the reason for the request. The agency will accommodate any reasonable request, although they may ask for payment of costs of mailing if they apply.
• The right to access and copy the designated record set--Unless HIPAA rules allow an exception (such as therapy notes, at the therapist's discretion), the agency must give clients an opportunity to access, inspect, and obtain a copy of the client's designated record set (DRS).
• The right to request amendments of the individual's DRS--The client has the right to request the agency to amend the medical record or other information in the DRS. The request must be in writing and include the reason to support the request. (The written request will be kept for at least six years.) Within 60 days, the agency must either accept the request and make the amendment, or deny the request in writing.
• The right to request an accounting of disclosures--Although there are stated exceptions, the agency must give the client an accounting of the disclosures it has made of the client's PHI in the six year prior to the request (HIPAA Patient's Rights: University of California Policy, 2010).

[QN.No.#5. Under HIPAA, a client does NOT have which of the following rights:]

In certain times and locations, there has been or is a stigma against receiving treatment for mental health. The confidentiality laws are in place to protect individuals from discrimination coming from this stigma. HIPAA protects not only disclosures made during treatment, but also the fact that the individual is in mental health treatment. This can also be a protection for family members and the therapist from potential danger should a violent individual who has intimidated the client learn that the individual is receiving support and from whom she's receiving it.

Confidentiality is generally counted on as a foundation of the therapist-client relationship. As a rule, therapy is most successful when the client trusts the therapist. The confidentiality laws help to preserve this trust. The therapist must never confirm or deny that an individual is or has been a client, unless there is a legal exception to the confidentiality. In addition, every detail of written and verbal communication in the course of assessment, treatment, testing, or any other communications are also protected as private information.

But there are some legal exceptions to confidentiality: threat of harm to self or others, involuntary commitment, a court order, certain lawsuits, suspicion of abuse of a minor or dependent adult, and detention of a mentally disordered person for evaluation.

• Threat of Harm to Self or Others:
  This includes risk of suicide and plans to physically harm someone else. When the threat of either of these is significant, which is often a judgment call, the client should be hospitalized for further evaluation and stabilization. The therapist will give the hospital all information needed for the hospitalization. The therapist should urge the client to go voluntarily, but involuntary commitment may be necessary. The therapist should explain the nature of the hospitalization process, the client's rights, how the therapist plans to support the process, and the client's ability to return to the current therapist after the hospitalization. This may help the client to cooperate.
• Involuntary Commitment:
  If the client does not cooperate, the therapist must notify the police to initiate evaluation by the resource the county designated to do these. Each state has a specific process to be followed for involuntary commitment. The therapist may give pertinent information about the client to appropriate authorities without client authorization in such situations.
• Dangerous Clients and Tarasoff:
  When a client or a member of his family reveals that the client poses a threat of grave bodily injury to an identifiable victim, the therapist must immediately notify both the potential victim and the police. "Tarasoff" refers to a California case when only the police were informed and the client killed a woman. The therapist was sued successfully for failing to warn such a victim. The therapist is not liable for making these disclosures.
• Criminal Activity:
  Criminal activity in itself is not required to be reported. Psychotherapy's worth to society would be significantly reduced if therapists were required to report all criminal activity, because this would prevent many from seeking treatment. The therapist must consider elements such as Tarasoff conditions and definitions of abuse.
• Detention of a Mentally Disordered Person for Evaluation:
  People who have become disabled to the point of not being able to adequately care for themselves are considered to be gravely disabled. In California these clients may be involuntarily hospitalized for 72 hours (more in some cases) for assessment. If it's determined that the individual continues to be gravely disabled, he may be held for an addition 14 days. Some circumstances, such as a threat of suicide, can cause another 14 day extension. At the end of that period, if the individual is determined to pose an imminent threat of harm, another 90-day extension may be given. Other states have similar rules.

[QN.No.#6. HIPAA makes some exceptions to confidentiality that include:]

Subpoena:
A lawsuit may end in a subpoena for client information. Because a subpoena is not a court order, some folks believe it doesn't have the same force. The reason is that subpoenas are usually sent out during the discovery phase of trial preparation. Attorneys are looking everywhere they can for information, not yet knowing what information will be helpful to them.
On the other hand, there are those who believe a subpoena has the same force as a court order (Your MFT Ethics, n.d.a). Your agency should have a guideline as to how you and the therapist should respond to a subpoena for client information. The agency will have conferred with their lawyers regarding their response. There are too many legal variables for you and your supervisees to attempt to respond on your own knowledge. Potential responses to protect client privacy include attempts to:

• Quash the subpoena, probably on a technicality
• State that you can neither deny nor confirm that any specific individual is a client and cannot release information from any client record without a court order or client consent.
• Modify the subpoena
• Negotiate with the issuer of the subpoena

The one thing you should never do is ignore it.

[QN.No.#7. Potential responses to a subpoena for client information never include:]


Court-Order Disclosures:
If the court orders a therapist to disclose client information when the client will not authorize a release, the therapist may cooperate with the court. Therapists are not expected to bear penalties for contempt of court; it's also assumed that the court has decided that society's needs in such a case override the values of confidentiality to either the client or society.

Reasonable Suspicion of Abuse of Neglect:
People in certain professions are legally mandated to report suspected or alleged abuse or neglect of children, elders, or dependent adults. Therapists are in that group. In this case, children are defined as people under age 18; elders are defined as people age 65 or older. The definition of dependent adults is people between 18 and 64 whose mental or physical limitations restrict their ability to care for themselves.

• Reporting: Mandated reported does not require that there is conclusive proof of neglect or abuse; rather, when functioning in her professional capacity, there is "reasonable suspicion" of abuse. The report is to be made to either the police or to the Department of Social Services. It must also be given in writing--by mail, fax, or electronically--within 36 hours for children or within two working days for adults.

Contacting authorities such as a child welfare agency does not necessarily constitute reporting; the therapist may contact them to help determine if the situation fits the mandatory reporting law. The California Welfare and Institutions Code only requires therapists to disclose information they happen upon in the course of profession activity, and only when there is a present danger. It may be considered present danger if an adult client reports past sexual abuse by a person currently in a household with children--the children may be at risk of abuse.

The therapist is not required to report a claim of neglect or abuse if the person reporting it has a mental illness or dementia, there is no corroborating information or evidence, and the therapist reasonably believes that the abuse didn't occur.

CANRA: In California, the law that pertains to abuse and neglect of children is largely in The California Child Abuse and Neglect Reporting ACT (CANRS). The purpose of the Act is "to protect children from abuse and neglect." Included in its intention is protection of the child's welfare during investigation: "In any investigation of suspected child abuse or neglect, all persons participating in the investigation of the case shall consider the needs of the child victim and shall do whatever is necessary to prevent psychological harm to the child victim."
(Source: Your MFT Ethics, n.d.a)

Releases of Information

The HIPAA laws protect the client's privacy. However, the client can overrule many of those laws by signing a release of information, a copy of which should remain in the client's record.

The laws allow for free use of client information for TPO, or "treatment, payment, or operations." The TPO uses of personal health information (PHI), as far as you and your supervisees are primarily concerned, might be summarized as free use within the agency that is providing the treatment, which includes:

• Use by the therapist that originated treatment notes for further treatment.
• Use or disclosure by the therapists for training programs under supervision to practice and improve their abilities in individual, family, joint, or group counseling.
• Use or disclosure by the therapist as defense in legal or other proceedings brought by the clients.

[QN.No.#8. HIPAA allows free use of client information for which of the following:]

Without a signed release of information, the therapist cannot even acknowledge whether or not an individual is or has been in therapy, let alone any particulars about treatment. The release of information is generally quite specific as to the time during which information may be released to which person or organization. HIPAA rules for release of information beyond the TPO state that the document must:

• Be written in plain language
• Be written in 8 point typeface or larger
• Be separate from all other documents
• Specifically describe health information to be used or disclosed
• State the name or function of the person or organization authorized to make such a disclosure
• State the date after which the provider can no longer disclose information
• State the name or function of the person or organization authorized to receive the information
• State specific uses and limitations of the use of the information by the persons authorized to receive it
• Advise patient of his right to receive a copy of the authorization
• Inform client of her right to revoke authorization under California law.
• Include a statement that the information used or disclosed may be subject to re-disclosure.

[QN.No.#9: HIPAA states that a release of information form must NOT:]

Because, without a release of information, you can only advise a referring organization that you cannot release requested information, it's important that you or your agency be sure that the staff of referring organization are aware that this can happen. Employee assistance professionals can aid in such situations in several ways. They can help employers establish company policies and train staff regarding issues such as confidentiality in compulsory referrals. Employee assistance professionals who are also clinicians may also counsel with employers on interpersonal and mental health issues to improve management staff's ability to improve morale, interact with employees, and decrease legal liability.