Informed Consent

 

PSYCHOLOGICAL COUNSELING
AND CONSULTING SERVICES

Steven T. Griggs, Ph.D.
Licensed Psychologist

    Encinitas Rancho                             PSY 8534
    Professional Park                                                     
    4407 Manchester Ave., #104*                                             210 S. Juniper St., #205
    Encinitas, CA 92024               Fax: (760) 471-1844              Escondido, CA 92025
    (760) 746-8355                       http://drgriggs.org                         (760) 746-8355

         

By signing below, I authorize treatment and accept responsibility for all charges incurred in this office. Counseling sessions, whether face-to-face or by telephone/video* are normally forty-five minutes in length and will be billed at the rate of (Insurance Company's rates or $100 if not using insurance benefits) per session. Telephone calls over five minutes, record copying and all other case-related tasks (for example, non-court-related letters, additional billing for court battles) will be charged at the rate of $2 per minute. This includes helping to figure out insurance benefits or fixing billing problems. To avoid unnecessary insurance hassles, I agree to make sure all services are covered (Insurance companies typically cover CPT Codes 90791, 90834, 90846 and 90847). I further agree to keep all personal information such as addresses and telephone numbers up to date, and to hold Dr. Griggs harmless for failure to do so. Anything having to do with attorneys or courts, including writing letters, making telephone calls, giving depositions or testifying, will be billed at the same rate that attorneys charge. I understand Dr. Griggs will bill my insurance company as a courtesy if I am not paying by cash or check, and that in order to do so I will provide the necessary information. By signing below, I authorize my signature to remain “on file” for billing purposes only. I also agree to keep any co-payment or deductible owed current on a thirty-day revolving basis, or pay a small monthly fee (a minimum of $5.00 or 1.5% of the unpaid balance, whichever is greater) for each thirty-day cycle re-billed. Said late payment fee shall not apply to monies forthcoming from insurance companies, only to outstanding co-payments or deductibles. Bounced checks incur additional charges, including a re-processing fee (typically $10), bank fees and/or penalties. Finally, should my account become delinquent (outstanding over sixty days), I agree to pay for all additional charges, fees or penalties incurred in attempting to collect. Presently, collection agencies charge Dr. Griggs about 60% of any submitted amounts.   Consequently, if my account goes to collections, I authorize Dr. Griggs to add this amount to the balance due prior to submitting it to cover their costs, without penalizing Dr. Griggs.

I agree to give Dr. Griggs twenty-four hours notice when I need to change or cancel appointments. I agree to notify him during normal business hours ONLY BY TELEPHONE.   NEITHER FAX, NOR TEXT NOR EMAIL IS TIMELY. TEXTS AND EMAILS SOMETIMES FAIL TO ARRIVE. Emails or texts that look like they may contain confidential information (scheduling or billing) will be deleted, unopened, for liability reasons. “Normal business hours” are Monday through Friday, 9:00 a.m. to 5:00 p.m., exclusive of holidays (which are treated like a weekend day)..   If I do not give twenty-four hours notice or if I notify him outside of normal business hours, e.g., on weekends or holidays, I will remain financially liable for the full billable amount of that appointment. To cancel a Monday appointment, I agree to call no later than the Friday before, at or earlier than the time of the appointment.   (For example, calling at 5:00 p.m. on Friday to cancel a 1:00 o'clock appointment the following Monday constitutes failure to give a 24 hour notice.)    For established clients, failed (no show, no call) appointments currently are charged $50 to cover office and appointment overhead.   New patient's who are not considerate enough to give 24 notice when cancelling, or worse, fail the very first appointment will be placed on a list and never called back.
 
I understand any information I communicate to Dr. Griggs will be held in confidence and will become part of my records, accessible only to Dr. Griggs. The exceptions to this are if I give my insurance/managed care company access to my records, or if I wish Dr. Griggs to bill my insurance/managed care company on my behalf. I understand records also can be surrendered under court ordered subpoena or via audit from the insurance company. In routine matters or third party communications having to do with my case information, I will sign a Release of Information form if records are to be released.  Because Dr. Griggs is a mandated reporter, per State regulations, confidentiality also will be broken in cases of child abuse, or clear suicidal or homicidal intent.   I will not send confidential information to Dr. Griggs via email or text, unless verbally waived in advance (e.g., during the COVID19 pandemic).

Finally, I understand that this agreement does not specifically guarantee that we will attain our therapeutic goals; however, it does constitute an offer on my part to contract with and to reimburse Dr. Griggs for access to his resources as a psychologist, and his willingness to apply his therapeutic resources in good faith.

____________________________
Client Signature/Date

 ___________________________
Dr. Steven T. Griggs/Date 

*Special Addendum: Video counseling/telehealth is available in all formats during the COVID 19 health crisis. Normally, only HIPAA-compliant software is allowed by the HHSA, but during the pandemic, popular forms of video counseling, which are NOT HIPAA compliant are now allowed, These include Facetime, WhatsApp,  Skype, Signal, Google Duo. I acknowledge that using these popular formats is not HIPAA compliant and waive all rights when conducting a session with Dr. Griggs. As soon as the COVID 19 health crisis is over, all video counseling will have to be over HIPAA-secure platforms. I have the option to use these HIPAA compliant platforms now and if I choose, and will inform Dr. Griggs which platform I prefer. Dr. Griggs will do his best to offer said platform(s) and to become proficient on each platform offered. Currently two platforms are HIPAA compliant--Doxyme and Sessions.   Both are free and require no downloads or installation of software.   I understand Dr. Griggs does not financially benefit from using any of the above platforms.   I further acknowledge that technological difficulties are common and that we may have interruptions or failures of audio or video signals before or during sessions.   Dr. Griggs will do his best to compensate by re-initiating sessions or switching to another format, or by using a combination of formats, e.g., using the video stream from an internet-based format and the audio signal via telephone.
    
     I acknowledge that I have contacted my insurance company to make sure they cover this service.   I acknowledge that the initial forms I send to Dr. Griggs, including this Informed Consent, Client and Insurance Information forms can be sent via fax, which is confidential.   I acknowledge that if I send these forms via attachments to Dr. Griggs' email or text, that said transmission is not HIPAA compliant.   I further acknowledge that Dr. Griggs will store this information in a secure way, on a separate hard drive not connected to the Internet, accessible only to Dr. Griggs.

Other special videocounseling/telehealth considerations: There are potential benefits and risks of video-conferencing that differ from in-person sessions.  Confidentiality still applies for telehealth services, and no one will record the session without permission. During the session I will provide a webcam and internet service/smart phone connection agreed to ahead of our session. I agree to be in a quiet, private space that is free of distractions. I agree to use a secure Internet connection (not a public or free Wifi). I agree to notify Dr. Griggs of my current physical location and to have a telephone nearby should the connection terminate. I agree to give Dr. Griggs this telephone number in advance if he does not have it on file. I am aware of the nearest emergency room, should one be needed. I agree to give permission to Dr. Griggs to work with my children, if appropriate, and that I give this permission as their legal guardian(s).

___________________________
Client Signature/Date

__________________________
Dr. Steven Griggs/Date

Scan this document and attach it to the special email for this purpose found on the bottom of this page and also on the telehealth page. Or, copy, print and fax this signed form to:

 

760.471.1844

 

 

onlyformsfordrgriggs@gmail.com

* This office is made available by another provider and is available as needed

 

 

 

 

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