Disclosure Statement

BONNIE M. TORELLA, MA, LCMHC

Passages Counseling & Development

4142 Robinhood Road, Winston-Salem, N.C. 27106

Office Phone:  336.608.8475

*CLIENT RIGHTS AND RESPONSIBILITIES

*POLICIES AND PRACTICES

 I am dedicated to providing professional individual, children, adolescent, couples, and family counseling. All clients have the right to be treated in a courteous, considerate, and dignified manner.

QUALIFICATIONS:

v  Masters in Counseling, Gardener Webb University: July, 2003

v  NCBLPC, #4545

v  25 Years counseling experience

COUNSELING BACKGROUND/SERVICES:

v  My experience includes 7 years as an Aftercare Counselor and 18 years in private practice.

v  My clients include individuals, couples, adolescents, and families.

v  I provide individual, couples, and family therapy utilizing Cognitive/Behavioral, Experiential, Human Givens, Family Systems, and Solution-Focused Therapies. 

      SESSIONS:

In-person and Telehealth appointments are scheduled upon consideration of individual needs and therapist availability. If you are unable to keep an appointment, please call to cancel at least 48 hours in advance to allow scheduling another client. Broken or Missed appointments without a 48 hour cancellation may be billed to the client at the full fee rate of $150.00 - OR- the rate of the insured's coinsurance charge and insurance charges combined.

PLEASE NOTE: The charge for broken/missed appointments MAY NOT be filed with your insurance company. 

 SESSION FEES AND LENGTH OF SERVICE:

v  Individual, couples, and family counseling sessions typically are 1 hour in length. However, treatment interventions that are longer in duration than the allowed 1 hour session by insurance MAY NOT be filed with your insurance company due to insurance not covering services that exceed 1 hour in duration per day. A private pay fee schedule will be applied for sessions exceeding the 1 hour commensurate to the duration of the session to the client or guardian (if client is a minor). Clients will be given informed consent as to the specific interventions recommended by the therapist as well as the cost to the client. 

v  When working with adolescents there may be part of the hour session time given to the parents.

v Private Pay session fees are $150.00/ 1 hour session; $225.00/1.5 hour session; $300.00 2 hour session per individual, couple and family session. When using insurance, charges vary are depending on insurance contracts, copay and deductible agreements. 

v  Methods of payment accepted are CASH, & CREDIT/DEBIT CARDS including Visa, MC, AND FLEXIBLE SPENDING ACCOUNT CARDS.

v  Payment is requested at each session unless prior arrangements are made with your therapist.

**PLEASE NOTE: Telehealth appointments are available for clients who wish to utilize this service. Please be aware that not all insurance companies offer this service as a benefit. In such cases, YOU, the client will be responsible for those charges to include the copay, coinsurance fees, and deductible if your insurance company denies the claim. It is the responsibility of the client or the guardian (if client is a minor) to inquire concerning Telehealth benefits with their insurance company. 

INSURANCE/PAYMENT:

v  I am in-network with Aetna, BCBS (with the exception of Blue Value and Blue Local plans), Blue Cross Blue Shield State Health Plans and Carolina Behavioral Health Alliance (CBHA).

v  I will file for insurance reimbursement with your permission for “in-network” benefits.

v  I will give you the appropriate insurance information required for reimbursement in order for you to file for “out-of-network” benefits should you decide to file your insurance claim. I am able to file out-of-network insurance claims with some insurance.

v  The ultimate determination of covered benefits is your responsibility with your insurance provider.

v  Payment of non-covered or denied services is the full responsibility of the client, or if a minor, the parent or guardian.

v  Private pay sessions are $150.00/ 1 hour session; $225.00/ 1.5 hour session; $300.00/ 2 hour session at the time of service.

v  Session payments are due at the time of service depending upon your insurance plan. This includes copays, deductibles and private pay.

PLEASE NOTE: In an effort to keep health care costs as low as possible a credit or debit card is required to be placed on the Client's account for payment.  All client information including credit/debit card information is kept in a secure location and will be treated as confidential. 

This practice will provide a "Credit Card Payment Authorization" form and will need to be signed and dated by the client authorizing this practice to use the credit/debit card for payment. The client has the right to refuse signing the "Credit Card Payment Authorization" form. However, if the client refuses this practice has the right to deny services. 

All client information including credit card information is kept in a secure location and will be treated as confidential. 

USE OF DIAGNOSIS:

vSome insurance companies will reimburse for counseling services and some will not. Additionally, most health insurance companies require a diagnosis code before they will reimburse. Some conditions for which people seek out counseling do not quality for reimbursement. If a qualifying diagnosis is appropriate in your case, I will inform you of the diagnosis code before submitting it to the health insurance company.

v Please be aware that any  diagnosis made will become a part of your permanent insurance/medical record.

NORTH CAROLINA HEALTH INFORMATION EXCHANGE AUTHORITY (NC HIEA): NC HealthConnex

Health information exchange systems have been developed since a federal law was passed in 2009 in order to promote the electronic movement and use of health information among health care providers. North Carolina's new, modernized health information exchange, now called NC HealthConnex, facilitates healthcare information between providers which promotes greater outcomes for patients, and creates efficiencies in state-funded health care programs such as Medicaid. 

NC HealthConnex is a secure computer system for doctors, hospitals, and other healthcare providers to share information that can improve the patient's care. The system links the patient's key medical information from all of their health care providers to create a single, electronic patient health record. Health care providers already share patient health records through fax, email, and mail when needed for the patient's care. NC HealthConnex makes receiving information easier, faster and more secure. By using HealthConnex providers see a more complete health record facilitating the best care possible to the client or patient. 

Your Choices as a Patient: Opting Out of NC HealthConnex

The NC General Assembly has created a way for patients to prevent information submitted to NC HealthConnex from being shared between participating healthcare providers, called "Opt-Out." If a patient submits an opt-out form to the NC HIEA, access to any information related to that patient maintained in the NC HealthConnex system will be blocked to health care providers who attempt to look up that patient.

Please note: Providers who recieve Medicaid or state funds (such as BCBS State Health Plan) for the provision of health care services are required by law to send data pertaining to health care services that are funded by the state.  Please discuss HIEA NC and HealthConnex with this provider should you have questions or choose to "opt-out" of NC HealthConnex.

ADMINISTRATIVE FEE:

In order to cover administrative costs, there will be a charge of $25.00 for requested written documentation by the client or the parent/guardian such as documentation needed to be provided to the school, college or employer. There is NO CHARGE when a request is made for information to be sent to another provider.  

COURT TESTIMONY:

If the court requires me to testify in court on your behalf, I will bill you at an hourly rate of $500.00 for the time that is spent on your case in or out of the office.  A deposit of $500.00 is REQUIRED PRIOR TO WORK BEING DONE ON YOUR CASE. COURT APPEARANCES AND ANY OTHER TIME SPENT ON YOUR CASE ARE NOT REIMBURSED BY INSURANCE. Because this service may become cost prohibitive it is recommended that you inform your attorney to only issue a subpoena when it is absolutely necessary to your case.

COMMUNICATION:

In order to better protect your personal healthcare information (PHI), HIPAA communication is required. Our practice offers confidential voicemail, a HIPAA compliant mobile texting app (OhMD), and the patient portal in order for this provider to be easily accessible to you. 

**PLEASE NOTE: Email, Electronic Transmittal, Wireless Telephone Communication (SMS texting), Mobile applications, and Web-based systems are subject to difficulties. Bonnie Torella, LCMHC, can not and does not guarantee confidentiality of such technology.

PHONE CONSULTATION/EMERGENCIES:

You may contact the practice at (336) 608.8475, OhMD text  and patient portal messaging. Since this is a solo practice, you may leave a confidential voicemail, OhMD, text or patient portal message. I strive to return calls, texts,and messages in between sessions or by the following business day Monday-Thursday. I am out of the office on Fridays and weekends and will return those calls, texts or messages the following business day of the next week.

Emergency calls should first be addressed by dialing 911 or going to your local emergency room. You are also welcome to contact this practice. 

If a consultation for a new client is requested, a 10/15 minute phone consultation is offered at no charge. If more time is needed for a consultation, the client will need to make a scheduled appointment. 

If you use other communication (ie. SMS texting, email) and not communication recommended by this practice (see above) you are agreeing by signing this document to use those methods of communication at your own risk of security and privacy of your healthcare information. 

All sessions are conducted in the therapist’s office. No counseling or advice will be given on the telephone unless prior arrangements have been made with the therapist. 

PRIVACY AND CONFIDENTIALITY:

The issues you discuss in counseling, including phone consultation, emails, texts, messages, and face to face communication, becomes a part of your clinical record. It is accessible to you upon request. Therapeutic consultation and subsequent notes are privileged information. Only necessary information will be shared with appropriate providers.

I will maintain confidentiality about anything that is said or written to me with the following exceptions:

v  You direct me in writing to disclose information to someone else.

v  You disclose information to me in which I determine you are a danger to yourself or someone else.

v  I am ordered by the court to disclose information.

v  Insurance providers require diagnosis codes, dates of service, and sometimes therapist evaluation and treatment planning.

 COMPLAINTS:

I abide by the NCBLCMHC, and the ACA Code of Ethics. Although clients are encouraged to discuss any concerns with me first, you may file a complaint against me with any of these organizations should you feel I am in violation of any of these codes of ethics.

North Carolina Board of Licensed Clinical Mental Health Counselors

Post Office Box 77819

Greensboro, NC 27417

Phone: 844.622.3572

Fax: 336.217.9450

Website: www.ncblcmhc.org 

Please let me know if you have any questions or concerns about any of my policies or practices.  Please sign below acknowledging that you have read, and understand this information. By signing you are agreeing to follow all policies, and practices in this document. 

_____________________________________________                                            

CLIENT SIGNATURE                                         Date

(Parent/Guardian must sign if client a minor)

_______________________________________       

THERAPIST SIGNATURE                                  Date