2021 HIPPA Agreement


Welcome to our practice. This document (the Agreement) contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a new federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that we obtain your signature acknowledging that we have provided you with this information at the end of this session. Although these documents are long and sometimes complex, it is very important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign that you have received this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on us unless we have taken action in reliance on it; if 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.


We provide both psychological evaluation and psychotherapy services. Evaluations typically consist of an effort to identify and explore the concerns that bring you to see us, documentation of our interviews, the results of any questionnaires or tests that we may administer, records from other sources about you and/or your child’s history and functioning, our interpretation of all data, and our diagnostic impressions, recommendations and plans for future contacts with you. Psychotherapy is not easily described in general statements. It varies depending on the personalities of the psychologist and patient, and the particular problems you are experiencing. There are many different methods we may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for a very active effort on your part. In order for the therapy to be most successful, you will have to work on things we talk about both during our sessions and at home.

Psychological services can have benefits and risks. Since meeting with a psychologist often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. Psychological testing often identifies areas that are both strengths and weaknesses, and some people may feel disheartened to learn of any learning difficulties they may have. On the other hand, this process has also been shown to have many benefits. Evaluations often lead to identification of steps that can be taken to improve your life and learning abilities. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. Unfortunately, there are no guarantees of what you will personally experience.

Our first few sessions will involve an evaluation of your needs. By the end of the evaluation, we will be able to offer you some feedback about our findings, and first impressions of what our work might include if a treatment plan is to follow, and if you decide to work with us in therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with us. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about our procedures, we should discuss them whenever they arise. If your doubts persist, we will be happy to help you set up a meeting with another mental health professional for a second opinion.


We normally conduct an evaluation that will last from 2 to 4 sessions. During this time, we will attempt to determine what your needs are, and we can both decide if we are the best person to provide any services that you need in order to meet your treatment goals. If psychotherapy is begun, we will usually schedule one 50-minute session (one appointment hour of 50 minutes duration) per week at a time we agree on, although some sessions may be longer or more frequent. Once an appointment hour is scheduled, you will be expected to pay for it unless you provide 48 hours advance notice of cancellation [unless we both agree that you were unable to attend due to circumstances beyond your control]. It is important to note that insurance companies do not provide reimbursement for cancelled sessions.[If it is possible, We will try to find another time to reschedule the appointment.]


In addition to face-to-face appointments, we charge for other professional services you may need, though we will break down the hourly cost if we work for periods of less than one hour. Other services include report writing, telephone conversations lasting longer than 10 minutes, consulting with other professionals with your permission, preparation of records or treatment summaries, and the time spent performing any other service you may request of us. If you become involved in legal proceedings that require our participation, you will be expected to pay for all of our professional time, including preparation and transportation costs, even if we are called to testify by another party. [Because of the difficulty of legal involvement, we charge a different rate for preparation and attendance at any legal proceeding. We can provide a breakdown of these fees, if requested.]


Due to our work schedule, we are often not immediately available by telephone. While we are usually in our office between 8 AM and 5 PM, and although we have an administrative assistant with whom you may speak, we probably will not answer the phone when we are with a patient. When no one is available, our telephone is answered by an answering machine, that we monitor frequently, and on which you may leave a message. We will make every effort to return your call on the same day you make it, with the exception of weekends and holidays. If you are difficult to reach, please inform us of some times when you will be available. If your call is urgent, you can try us through our e-mail addresses which are provided on our vitae page of our website, www.thenichollsgroup.com. If you are unable to reach us and feel that you can’t wait for us to return your call, contact your family physician or the nearest emergency room and ask for the psychologist [psychiatrist] on call. If we will be unavailable for an extended time, we will provide our office with the name of a colleague to contact, if necessary.


The law protects the privacy of all communications between a patient and a psychologist. In most situations, we can only release information about you to others if you sign a written Authorization form that meets certain legal requirements imposed by HIPAA and Arizona state law. There are other situations that require only that you provide written, advance consent. Your signature on this Agreement acknowledges those activities, as follows:

  • We may occasionally find it helpful to consult other health and mental health professionals about a case. During a consultation, we make every effort to avoid revealing the identity of our patient. The other professionals are also legally bound to keep the information confidential. If you don’t object, we will not tell you about these consultations unless we feel that it is important to our work together. We will note all consultations in your Clinical Record (which is called “PHI” in our Notice of Psychologist’s Policies and Practices to Protect the Privacy of Your Health Information).
  • You should be aware that we share an office with other professionals and that we employ administrative staff. In most cases, we need to share protected information with these individuals for both clinical and administrative purposes, such as scheduling, billing and quality assurance. All of the professionals are bound by the same rules of confidentiality. All staff members have been given training about protecting your privacy and have agreed not to release any information outside of the practice without the permission of a professional staff member.
  • We also use the services of an accountant. As required by HIPAA, we have a formal business associate contract with this business, in which it promises to maintain the confidentiality of this data except as specifically allowed in the contract or otherwise required by law. If you wish, we can provide you with the names of this organization and/or a blank copy of this contract. Please note that accounting records do not, as a rule, contain personally identifiable information regarding our clients, and that personally identifiable information is not included in bank deposit slips, etc.
  • Disclosures required by health insurers or to collect overdue fees are discussed elsewhere in this Agreement.
  • If a patient threatens to harm himself/herself, we may be obligated to seek hospitalization for him/her, or to contact family members or others who can help provide protection

There are some situations where we are permitted or required to disclose information without either your consent or authorization:

  • If you are involved in a court proceeding and a request is made for information concerning the professional services we provided you, such information is protected by the psychologist-patient privilege law. We cannot provide any information without your or your legal representative’s written authorization, or a 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 us to disclose information. If a government agency is requesting the information for health oversight activities, we may be required to provide it for them.
  • If a patient files a complaint or lawsuit against us, we may disclose relevant information regarding that patient in order to defend ourselves.
  • If a patient files a worker’s compensation claim, and we are providing services related to that claim, we must, upon appropriate request, provide appropriate reports to the Workers Compensation Commission or the insurer.

There are some situations in which we are legally obligated to take actions, which we believe are necessary to attempt to protect others from harm and we may have to reveal some information about a patient’s treatment. These situations are unusual in our practice.

  • If we have reason to believe that a child under 18 who we have examined is or has been the victim of injury, sexual abuse, neglect or deprivation of necessary medical treatment, the law requires that we file a report with the appropriate government agency, usually the Arizona Department of Child Safety. Once such a report is filed, we may be required to provide additional information.
  • If we have reason to believe that any adult patient who is either vulnerable and/or incapacitated and who has been the victim of abuse, neglect or financial exploitation, the law requires that we file a report with the appropriate state official, usually a protective services worker. Once such a report is filed, we may be required to provide additional information.
  • If a patient communicates an explicit threat of imminent serious physical harm to a clearly identified or identifiable victim, and we believe that the patient has the intent and ability to carry out such threat, we must take protective actions that may include notifying the potential victim, contacting the police, or seeking hospitalization for the patient.

If such a situation arises, we will make every effort to fully discuss it with you before taking any action and we will limit our disclosure to what is necessary.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns that you may have now or in the future. The laws governing confidentiality can be quite complex, and we are not attorneys. In situations where specific advice is required, formal legal advice may be needed.


The laws and standards of our profession require that we keep Protected Health Information about you in your Clinical Record. This record includes information about your reasons for seeking evaluation and/or therapy, a description of the ways in which your problem impacts on your life, the results of any testing or evaluation procedures, your diagnosis, the goals that we set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that we receive from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in unusual circumstances that involve danger to yourself and/or others or where information has been supplied to me confidentially by others, you may examine and/or receive a copy of your Clinical Record if you request it in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in our presence, or have them forwarded to another mental health professional so you can discuss the contents. [We are sometimes willing to conduct this review meeting without charge.] If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.


HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that we amend your record; requesting restrictions on what information from your Clinical Record is disclosed 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 of this Agreement, the attached Notice form, and our privacy policies and procedures. We are happy to discuss any of these rights with you.


Patients under 18 years of age who are not emancipated, and their parents, should be aware that the law may allow parents to examine their child’s treatment records. Because privacy in psychotherapy is often crucial to successful progress, particularly with teenagers, it is sometimes our policy to request an agreement from parents that they consent to give up their access to their child’s records. If they agree, during treatment, we will provide them only with general information about the progress of the child’s treatment, and his/her attendance at scheduled sessions. We will also provide parents with a summary of their child’s treatment when it is complete. Any other communication will require the child’s authorization, unless we feel that the child is in danger or is a danger to someone else, in which case, we will notify the parents of our concern. Before giving parents any information, we will discuss the matter with the child, if possible, and do our best to handle any objections he/she may have.


You will be expected to pay for each appointment at the time it is held, unless we agree otherwise or unless we have an agreement that another party will pay for the services. Payment schedules for other professional services will be agreed to when they are requested. If your account has not been paid for more than 60 days and arrangements for payment have not been agreed upon, we have the option of using legal means to secure the payment. This may involve hiring a collection agency or going through small claims court which will require us to disclose otherwise confidential information. In most collection situations, the only information we release regarding a patient’s treatment is his/her name, the nature of services provided, and the amount due. [If such legal action is necessary, its costs will be included in the claim.] We have a "48 business hour cancellation policy" for meetings/psychotherapy appointments and 72 business hours for any testing that is schduled. We request that you put a credit card number on file during your initial contact with our office to assure that any late fees, no-show appointments or late-cancellation fees are proccessed as agreed.


In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. We ask that you pay our fees, at the time of service. Our office does not submit claims to insurance companies, and we are not bound by any limitations, restrictions, or fee schedules set by your insurance company. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will provide you with procedure and diagnostic codes and whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your insurance company) are responsible for full payment of our fees. It is very important that you find out exactly what mental health services your insurance policy covers.

You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company.

You should also be aware that your contract with your health insurance company may require that we provide it with information relevant to the services that we provide to you. A clinical diagnosis is typically required in order for insurance companies to provide reimbursement for services. Sometimes we are required to provide additional clinical information such as treatment plans or summaries, or copies of your entire Clinical Record. In such situations, we will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of the insurance company files and will probably be stored in a computer. Though all insurance companies claim to keep such information confidential, we have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any report we submit, if you request it. By signing this Agreement, you agree that we can provide requested information to your carrier.