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Terms and Policy

Informed Consent

Welcome! The following provides you information about working together. Please read through this carefully and we will discuss any questions you have in our initial consultation meeting.


PSYCHOLOGICAL SERVICES

Psychotherapy requires a very active role. It can have benefits and risks. Psychotherapy usually involves discussing unpleasant parts of life and you may experience an increased in symptoms including anger, sadness, and anxiety. However, there are also many benefits to psychotherapy and mental illnesses left   untreated may be harmful to one's physical and mental health.


The first one to two sessions are an evaluation of your needs to determine if we will work together for treatment. We will develop a treatment plan which may include education, individual, group, couples, family therapy, or other referrals/recommendations that are medically necessary and/or potentially beneficial to your mental health. We can discuss any questions or concerns you may have at any point during our work together.


Please note: I do not complete assessments or related paperwork for disability claims, emotional support animals or service animals. 


CONFIDENTIALITY

Your privacy is important to me. I will not disclose any information about you unless you give me written permission to do so. However, there are times when I am required to release information, even without your permission, in accordance with the American Psychological Association Code of Ethics and/or the laws of the State of Minnesota.


These situations include (not complete list):

1) If you threaten to take your own life or someone else's life

2) If there is any indication of abuse or neglect involving a child, vulnerable adult due to mental or physical disabilities. This includes a pregnant woman's use of alcohol or non-prescribed controlled substances.

3) If I receive a subpoena or court order to requesting information

4) If you sign a "Release of Information/Authorization" form, I can provide and/or receive information from the identified person/agency etc.. any and all information that you have authorized.

5) I may seek consultation from a group of other psychologists about our work together to help me provide the best care for you. If I discuss your case, I do not provide your name or other identifying information. Case consultations are recommended by the MN Board of Psychology.


PROFESSIONAL RECORDS

As a licensed psychologist, I am required to keep records of our sessions. All records are stored in secure, HIPAA compliant Electronic Health Record (EHR) system. A Business Associate Agreement was obtained with this EHR company to ensure your PHI is properly safeguarded. You are entitled to receive a copy of these records. Rarely, I may refuse to disclose particular content of the records if I feel they may be emotionally damaging, in which case I may provide a brief summary. I recommend you review your records in my presence to address and questions or concerns.


PATIENT RIGHTS

HIPAA provides you with several new or expanded rights with regard to your Clinical Records and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Records 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 my policies and procedures recorded in your records; and the right to a paper copy of this Agreement, the HIPAA Notice form located on my website (DrShellyCurran.com), and my privacy policies and procedures. I am happy to discuss any of these rights with you.


MINORS and PARENTS

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 my 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, I will provide them only with general information about the progress of the child's treatment, and his/her attendance at scheduled sessions. I will also, upon request, provide parents with a summary of their child's treatment when it is complete. Any other communication will require the child's Authorization, unless I feel that the child is in danger or is a danger to someone else, in which case, I will notify the parents of my concern. Before giving parent any information, I will discuss the matter with the child, if possible, and do my best to handle any objections he/she may have.


APPOINTMENTS, FEES, and INSURANCE COVERAGE

Initial evaluation appt (75 mins) is $250.  Follow-up appointments (53 mins) cost $200 per session for individuals, couples, or families.

I do not accept insurance for payment of services. Upon payment, I can provide you a receipt/documentation generally needed so you can submit out of network insurance or health savings account (HSA, flexible spending accounts etc..) requests. This receipt/documentation includes your PHI such as diagnosis and type of psychological service received, etc... You (not your insurance company etc..) are responsible for full payment of therapy fees at the start of each session.


Please note:  I cannot treat anyone covered by Medicare insurance in my private practice as I am a Medicare provider in a clinic separate from my private practice. 


You are responsible for any collections, legal, or other fees involved in collecting any outstanding balances owed by you.


No Surprise Billing: Section 2799B-6 of the Public Health Service Act requires health care providers and facilities to inform individuals who are uninsured or self-pay (not using insurance) a Good Faith Estimate of expected fees for services when scheduling care or upon request.  Make sure to save a copy or picture of your Good Faith Estimate.  For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.


MISSED and LATE CANCELLED APPOINTMENTS

You will be billed the full session fee if you miss an appointment or cancel less than 24 hours before your appointment.  If you are more than 15 mins late for an initial consultation session, your session will be cancelled and you will be billed for the full session fee of $250. 


CONTACTING ME

Please call me at 612-400-7460 and I will usually be able to return your call on the same day or the next day if your call is after 5:00pm. If you are in crisis or your need is urgent, please include this in your message to me. Current patients can also contact me through the secure patient portal link obtained when you registered and also on my website: www.Dr.ShellyCurran.com.  Preferred communication with current patients is through the secure patient portal.  Email communication and text messaging is only used for administrative purposes (e.g,. changing appts, running late, etc..) unless we have made another agreement.  Please do not email or test me about clinical matters at these types of communications are not secure.


I do not communicate with or contact any of my patients through social medal platforms nor do I use web searches to gather information about my patients.  Please note mental health providers cannot respond to reviews on health care provider websites. Please contact me if you have any questions or concerns. 


If you are in crisis or have an emergency please contact your nearest emergency room. Other resources include: Hennepin County (612) 596-1223, Scott County (952) 442-7601, or Crisis Connection (all counties) (612) 379-6363



The informed consent will be valid until you are discharged from treatment and you have the right to withdraw consent at any time during treatment, in writing.


Please sign below to indicate that you have read the about "Informed Consent" and agree to abide by its terms during our professional relationship.

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Notice of Privacy Practices for Protected Health Information

This notice describes how psychological and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.


Shelly L. Curran, PhD, LP/Behavioral Medicine Associates, PLLC (BMA) has established a policy to guard against unnecessary disclosure of your health information. BMA and providers providing care at BMA may use/disclose your personal health information (PHI) as defined in the Privacy Rule of the Health Insurance Portability and Accountability Act (HIPAA) with your consent, for the following purposes:

Providing Treatment. When I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another health care provider, such as your family physician or another psychologist.

Obtaining Payment. I do not accept insurance for payment of services. However, if you request written documentation for you to submit possible out of network benefits, HSA payments, etc.. that documentation will include your PHI (such as diagnosis and type of psychological service etc...).

Conducting Health Care Operations. These are activities that relate to the performance and operation of my practice. Examples of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.

Uses and Disclosures Requiring Authorization


I may use or disclose PHI for purposes outside of treatment, payment, or health care operations when your appropriate authorization is obtained. An "authorization" is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or health care operations, I will obtain a written authorization from you before releasing this information.


You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining reimbursement for insurance coverage, and the law provides the insurer the right to contest the claim under the policy.


Uses and Disclosures with Neither Consent nor Authorization: I may use or disclose PHI without your consent or authorization in the following circumstances:


Child Abuse: If I have reasonable cause to suspect that a child seen in the course of my professional duties has been abused or neglected, or have reason to believe that a child seen in the course of my professional duties has been threatened with abuse or neglect, and that abuse or neglect of the child will occur, I must report this to the relevant county department, child welfare agency, police, or sheriff's department.


Adult and Domestic Abuse: If I have reason to believe that a vulnerable adult is being or has been maltreated, or if I have knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained, I must immediately report the information to the appropriate agency in this county. I may also report the information to a law enforcement agency.


"Vulnerable adult" means a person who, regardless of residence or whether any type of service is received, possesses a physical or mental infirmity or other physical, mental, or emotional dysfunction that impairs the individual's ability to provide adequately for the individual's own care without assistance, including the provision of food, shelter, clothing, health care, or supervision; and because of the dysfunction or infirmity and the need for assistance, the individual has an impaired ability to protect the individual from maltreatment.


Health Oversight: The Minnesota Board of Psychology may subpoena records from me if they are relevant to an investigation it is conducting.


Judicial or administrative proceedings: If you are involved in a court proceeding and a request is made for information about your diagnosis and treatment and the records thereof, such information is privileged under state law and I will not release the information without written authorization from you or your personal or legally-appointed representative, or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance, if this is the case.


Serious Threat to Health or Safety: If you communicate a specific, serious threat of physical violence against a specific, clearly identified or identifiable potential victim, I must make reasonable efforts to communicate this threat to the potential victim or to a law enforcement agency. I must also do so if a member of your family or someone who knows you well has reason to believe you are capable of and will carry out the threat. I also may disclose information about you necessary to protect you from a threat to commit suicide.


Worker's Compensation: If you file a worker's compensation claim, a release of information from me to your employer, insurer, the Department of Labor and Industry or you will not need your prior approval.


Other: When the use and disclosure without your consent or authorization is allowed under other sections of Section 164.512 of the Privacy Rule and the MN state confidentiality law. This includes certain disclosures to law enforcement agencies, a coroner or medical examiner, for public health purposes relating to disease or FDA regulated products, or for specialized government functions such as fitness for military duties, eligibility for VA benefits, and national security and intelligence.


There may be additional disclosures of PHI that I am required or permitted by law to make without your consent or authorization, however the disclosures listed above are the most common.


PATIENT RIGHTS:


Request Restrictions You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, I am not required to agree to a restriction you request.


Right to Restrict Disclosures When you have Paid for Your Care Out-of-Pocket You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of-pocket in full for my services.


Receive Confidential Communications You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing me. Upon your request, I will send your bills to another address.)


Inspect and Copy (paper or electronic)You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. On your request, I will discuss with you the details of the request process.


Amend your PHI You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss with you the details of the amendment process.


Right to an Accounting You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, I will discuss with you the details of the accounting process.


Right to a Paper Copy- You have the right to obtain a paper copy of the notice from me upon request, even if you have received this notice previously.


Right to be Notified in There is a Breach of Your Unsecured PHI You have a right to be notified if; (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards: and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.


Questions and Complaints


If you have questions about this notice, disagree with a decision I make about access to your records, or have other concerns about your privacy rights, you may the Privacy Officer, Shelly L. Curran PhD, LP at 612-400-7460.


If you believe that your privacy rights have been violated and wish to file a complaint with me, you may send your written complaint to Shelly L. Curran, PhD, LP, 3209 W. 76th Street, Suite 202A, Edina, MN 55435


You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. The person listed above can provide you with the appropriate address upon request.


You have specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.


Shelly L Curran PhD, LP / BMA, PLLC is required by law to maintain the privacy of your PHI, to abide to terms of the notice and reserves the right to change the terms of its notice and make the new notice provisions effective for all PHI that it   maintains. If there is a material change to this notice, you can obtain a copy of the revised notice at my office or on my website. This notice is effective September 27, 2017 unless and until revised by BMA. Any questions regarding this notice, please contact Privacy Officer: Shelly L Curran, PhD, LP (612) 400-7460.

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Missed/Late Cancellation Policy

If you need to cancel an appointment, please call me at 612-400-7460 at least 24 hours before your appointment (e.g., a Friday 2:00pm appt must be cancelled no later than Thursday 2:00pm).  You will be billed the full session fee ($250 for initial session or $200 for follow-up session) if you miss an appointment or cancel less than 24 hours before your appointment.  If you are more than 15 mins late for an initial consultation session, your session will be cancelled and you will be billed for the full session fee of $250.

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