DISCLOSURE STATEMENT

 

This statement is being provided to you by Truecare24 and its business associates, so that you are aware of your rights as a patient .This document contains important information about Truecare24 and its business associates’ policies as well as counseling sessions.  Please read this and discuss any questions or concerns you have with your healthcare professional .  Your provider’s license, qualifications, and contact information are listed at the end of this document.



YOUR RIGHTS AS A PATIENT

Except in an emergency situation, or where psychotherapy is being administered pursuant to a court order, every Licensed Psychotherapist, Licensed Social Worker, Licensed Mental Health Counselor,  unlicensed psychotherapist,or psychologist shall provide the information below in writing to each client at the initiation of therapy. 

The Texas State Board of Examiners of Professional Counselors has the general responsibility of regulating the practice of licensed psychologists, licensed social workers, licensed professional counselors, licensed marriage and family therapists, licensed school psychologists practicing outside the school setting and unlicensed individuals who practice psychotherapy.  

Importantly, you have the right to receive ethically sound and professional services from your counselor. Your counselor aims to provide services in a professional and ethical manner within accepted legal standards. If you are ever dissatisfied with your therapy, please directly discuss these concerns with your counselor. If they are not able to resolve these issues you may report complaints to the [email protected]

You are entitled to receive information about methods of therapy, the techniques used, the duration of your therapy (if it can be determined), and fee structure.  You may seek a second opinion from another therapist and you can terminate services at any time.  Your therapist may refer you to another provider if the issues brought up in therapy are outside of the scope of practice, or beyond their training, experience and/or competence.  

In a professional relationship (such as between you and your therapist), sexual intimacy between a therapist and a client is never appropriate.  If sexual intimacy occurs, it should be reported to the Texas State Board of Examiners of Professional Counselors.

Psychological Services
Psychotherapy is not easily described in general statements. It varies depending on the particular problems you hope to address. There are many different methods your therapist may use to deal with those problems.  Psychotherapy is not like a medical doctor visit. Instead, it requires active participation  on your part. In order for the therapy to be most successful, you will have to work on things you talk about in and out of therapy. 

Psychotherapy can have benefits and risks. Because therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, loneliness, and helplessness. On the other hand, psychotherapy has also been shown to have benefits for people who go through it. Therapy often leads to better relationships, solutions to specific problems, and significant reductions in feelings of distress. But, there are no guarantees as to what you will experience. 

You will be assigned a primary therapist but may be seen by an interim therapist to ensure continuity of care.Your first few sessions will involve an evaluation of your needs. By the end of the evaluation, your therapist will be able to offer you some first impressions of what your treatment plan will include, if you decide to continue with therapy. You should evaluate this information along with your own opinions about whether you feel comfortable working with your therapist. At the end of the evaluation, your therapist will notify you if he or she believes that they are not the right therapist for you and, if so, will give you referrals to other practitioners whom he or she believes are better suited to help you.  

If you have questions about your therapist’s procedures, you should discuss them whenever they arise. If your doubts persist, a TrueCare24 liaison can help you find another therapist that may fit your needs better. Your therapist will normally conduct an initial evaluation that may last a couple of sessions. During this time, a decision can be made if your therapist is the best person to provide the services you need in order to meet your treatment goals. If you agree to begin psychotherapy, your therapist  will schedule 30 minutes to 1 hour therapy sessions weekly, although some sessions may be longer or more frequent. To provide continuity of care in the event your primary assigned therapist is not available you may be seen by another qualified therapist employed by Truecare24

Contacting Your Therapist  

Truecare24 and its business associates do not provide emergency psychiatric services, if you are experiencing a behavioral health crisis please call 911 or go to the nearest emergency room for help. For all non-emergent issues please leave a voicemail with your provider’s answering service. Your provider will try to contact you within 72 hours depending on their availability.You may contact Truecare24 and its business associates to connect you with your therapist at [email protected] or (240) 434-0963. If you are difficult to reach, please inform Truecare24 and its business associates of some times when you will be available. If you are unable to reach your therapist and feel that you cannot wait, contact your family physician or the nearest emergency room. If your primary assigned therapist will be unavailable for an extended time, Truecare24 and its business associates will provide you an interim therapist, if necessary. 

Insurance Reimbursement 

If you have a health insurance policy including Medicare or Medicaid, it will usually provide some coverage for mental health treatment. 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. 

You should also be aware that most insurance companies require that your therapist  provide them with your clinical diagnosis. Sometimes your insurance company may ask Truecare24 and its business associates to provide additional clinical information, such as treatment plans, progress notes or summaries, or copies of the entire record (in rare cases). This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, Truecare24 and its business associates 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. Truecare24 and its business associates will provide you with a copy of any records we submit, if you request it. You understand that, by using your insurance, you authorize Truecare24 and its business associates to release such information to your insurance company. Truecare24 and its business associates will only share information that is required by your insurance company and will respect and abide by HIPAA per your insurance companies agreed upon requirements.  

Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for  services yourself to avoid the problems described above [unless prohibited by the insurance contract].

Copay Acknowledgement

I authorize Truecare24,its business associates, and associated mental healthcare providers to bill my insurance for medical services provided to me. I also authorize Truecare24,its business associates, and associated mental health care providers  to bill my credit/debit or checking account on file to cover the cost of any copay related to the medical services I receive.


ELECTRONIC COMMUNICATION POLICY 

Electronic Communication Policy

Introduction

In order to maintain clarity regarding Truecare24 and its business associates’ use of means of communication during your treatment, we have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of your therapist’s profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with your therapist. 

EMAIL COMMUNICATIONS

Truecare24 and its business associates use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with Truecare24  and its business associates should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email Truecare  and its business associates about clinical matters because email is not a secure way to send protected health information (PHI) to Truecare24 and its business associates. If you need to discuss a clinical matter with your therapist please feel free to call Truecare24 and its business associates so we can discuss it on the phone or during your therapy session. The telephone or face-to-face context is a more protected means for these communications. 



Text Messaging

Because text messaging is a very insecure and impersonal mode of communication, Truecare24 and its business associates does not permit therapists to text message or respond to text messages from clients in treatment.  So, please do not text message your therapist  unless we have made other arrangements.

SOCIAL MEDIA

Therapists employed by Truecare24 and its business associates do not communicate with, or contact, any  clients through social media platforms like Twitter and Facebook. In addition, if Truecare24 and its business associates discover that your therapist has accidentally established an online relationship with you, Truecare24 and its business associates will terminate  that relationship. This is because these types of casual social contacts can create significant security risks for you.

Therapists employed by Truecare24 and its business associates may participate on various social networks, but not in any professional capacity. If you have an online presence, there is a possibility that you may encounter your therapist. If that occurs, please discuss it with your therapist or during your scheduled session. Truecare24 and its business associates believe that any communications with clients online have a high potential to compromise the professional relationship. In addition, please do not try to contact your therapist, or Truecare24 and its business associates in this way. Your therapist will not respond and will terminate any online contact no matter how accidental.

WEBSITES

Truecare24 and its business associates have a website that you are free to access. It is used for professional reasons to provide information to others about Truecare24 and its business associates and services provided. You are welcome to access and review the information that Truecare24 and its business associates have on its

WEB SEARCHES

Your therapist employed by Truecare24 and its business associates will not use web searches to gather information about you without your permission. Truecare24 and its business associates believe that this violates your privacy rights; however, we understand that you might choose to gather information about Truecare24 and its business associates in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about Truecare24 and its business associates, your therapist through web searches, or in any other fashion for that matter, please discuss this with your therapist during your time together so that we can deal with it and its potential impact on your treatment. 

Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of Truecare24 and its business associates or any professional with whom you are working, please share it with Truecare24 and its business associates so we can discuss it and its potential impact on your therapy. Please do not rate your therapist work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.

Confidentiality  

What you discuss in sessions is kept confidential between you and your therapist. No content of the sessions may be shared with another party without your written consent or the written consent of the parent/legal guardian of a minor. However, there are times when counselors are required, by law and professional ethics, to break confidentiality and file a report. Those exceptions are: 

  • Texas state law requires licensed professional counselors who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age to report this information to authorities. 
  • Texas state law requires licensed professional counselors who learn of, or strongly suspect, physical or sexual abuse or neglect of an elderly person to report this information to authorities. 
  • If there is evidence of clear and imminent danger of harm to self and/or others, counselors may be legally required to report this information to the authorities responsible for ensuring safety. 
  • Parents or legal guardians of non-emancipated minor clients have the right to access clients’ records.
  • Counselors may be ordered by the court to disclose information.
  • If you or your child is involved in legal action/proceedings, your records may be subject to subpoena or lawful directive from a court.
  • You or your child discloses sexual contact with another mental health professional who has or is providing health care services to you or your child

    Your therapist may occasionally find it helpful to consult other professionals about a case. During a consultation, your therapist will make every effort to avoid revealing the identifying information. The consultant is also legally bound to keep the information confidential. Ordinarily,your therapist will not tell you about these consultations unless it is important to our work together.

PROFESSIONAL RECORDS

Laws and standards require that your personal Protected Health information are kept secure in your clinical record.  Except in unusual circumstances that involve danger to yourself and/or others, you may examine and/or receive a copy of your clinical record if you request it in writing to Truecare24  and its business associates.  Your therapist will  keep very brief records, noting only that you were seen, what interventions were implemented, and progress toward treatment goals.  Truecare24 and its business associates will maintain your clinical records in a secure location.  Your records will be destroyed after the termination of your treatment if it is required by law within required by law timeframe.

Provider Information 

List all active therapists that could potentially treat clients.

Last Name, First Name. Credentials. Education. email address. Truecare24 and its business associates Contact Phone Number

DOE, JANE. LCSW. Masters degree in social work from Manhattan University. email address. Truecare24 Contact Phone Number

[autogenerate

  • Montgomery, Jolanna, LCSW, NPI 1871250985, Masters degree in social work from University of Houston. [email protected], (240) 434-0963
  • Thies-Jernigan, Radonna, LCSW, NPI 1497700025, Masters degree in social work from Our Lady of the Lake University. [email protected], (240) 434-0963
  • Russ, Inger, LCSW, NPI 1417609629, Masters degree in social work from South Carolina University. [email protected], (240) 434-0963
  • Garrett, Shaunquette, LCSW, NPI 1669146940, Masters degree in Social Work from University of Houston, [email protected], (240) 434-0963
  • Brown, Leah, LCSW, NPI 1821667361, Masters degree in social work from Florida A&M University.[email protected], (240) 434-0963
  • Lear, Sharla, LCSW, NPI 1548579980, Masters degree in social work from Texas University in Austin, [email protected], (240) 434-0963
  • Armstrong, Lucille, LCSW, NPI 1194052894, Masters degree in social work from Texas  University in Arlington. [email protected], (240) 434-0963
  • Blackshear, Krysten, LCSW, NPI 1255906897, Masters degree in social work from Stephen F. Austin State University. [email protected], (240) 434-0963
  • Bolden, Sonya, LCSW, NPI 1073850657, University of Illinois at Urbana Champaign [email protected], (240) 434-0963
  • Sang, Catherine, LCSW, NPI 1255947578, Masters from University of Texas at Arlington [email protected], (240) 434-0963
  • Hargrove, Yolanda, LCSW, NPI 1881353969, Masters degree in social work from Texas A&M Commerce [email protected], (240) 434-0963 
  • Greenwood, Denise, LCSW-S, NPI, 1366826000, Masters degree in social work from University of Houston   [email protected], (240) 434-0963 


CONSENT AND AGREEMENTS

Please sign a copy of this form and keep a copy for yourself.  Your signature will indicate that you have read this form, that you have your copy, that you understand your rights and you have received HIPAA information.  By signing this form, you give your consent for treatment and share required HIPAA protected information with TrueCare and it’s business associates. 

 By signing this form, you give consent for another licensed mental health professional employed by Truecare24 and its business associates to conduct your treatment and to take possession of your clinical records in the event that your primary assigned therapist needs replacement or upon your request for another therapist. 

Your signature also allows Truecare24, its business associates and your therapist  to release information necessary to process insurance claims and authorize payment (including Medicare) directly to Truecare24 and its business associates for services provided.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship. 

    

AUTHORIZATION FOR RELEASE/DISCLOSURE OF INFORMATION

 

I hereby authorize the release/request of copies and/or discussion of the information included medical/psychological history, medications and current symptoms for coordination of care.  I authorize Truecare24, its business associates and my assigned therapist to bill my insurance company. 

I may revoke this authorization in writing at any time by sending an email to [email protected].  If not revoked prior to the end of treatment with Truecare24 this consent will automatically expire 30 days after termination of services, unless otherwise specified.

 I confirm that I understand that in the event that information has already been shared by the time authorization is revoked, it may be too late to cancel permission to share the health data, that I do not need to give any further permission for the information detailed above to be shared with the person(s) or organization(s) listed, and that the failure to sign/submit the authorization of the cancellation of this authorization will not prevent the reception of treatment or benefits the client is entitled to receive, provided this information is not required to determine eligibility to receive those treatments or benefits or to pay for the services I receive. 


TrueCare24 PhysiciansGroup, S.C
Telehealth Treatment Consent

Information and Informed Consent for Telemental Health Treatment
Telemental health is live two – way audio and video electronic communications that allows therapists and clients to
meet outside of a physical office setting.

Client Understanding

I understand that telemental health services are completely voluntary and that I can withdraw this consent at any
time.

I understand that none of the telemental health sessions will be recorded or photographed.

I agree not to make or allow audio or video recordings of any portion of the sessions.

I understand that the laws that protect privacy and the confidentiality of client information also apply to telemental
health, and that no information obtained in the use of telemental health that identifies me will be disclosed to other
entities without my consent.

I understand that telemental health is performed over a secure communication system that is almost impossible for
anyone else to access. I understand that any internet based communication is not 100 % guaranteed to be secure.

I agree that the therapist and practice will not be held responsible if any outside party gains access to my personal
information by bypassing the security measures of the communication system.

I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical
difficulties.

I understand that I or my therapist may discontinue the telemental sessions at any time if it is felt that the video
technology is not adequate for the situation.

I understand that if there is an emergency during a telemental health session, then my therapist may call
emergency services and/ or my emergency contact.

I understand that this form is signed in addition to the Notice of Privacy Practices and Consent to Treatment and
that all office policies and procedures apply to telemental health services.

I understand that if the video conferencing connection drops while I am in a session, I will have an additional phone
line available to contact my therapist, or I will make additional plans with my therapist ahead of time for re – contact.

I understand a “no show” or late fee will be charged if I miss an appointment or do not cancel within 24 hours of
scheduled appointment. I understand credit card or other form of payment will be established before the first
session.

I understand my therapist will advise me about what telemental health platform to use and she will establish a video
conference session.