The information provided in this document is meant to acquaint you with our policies. Good communication is the foundation of effective care, so please let us know if you have questions or concerns about any matters relevant to your treatment. We are honored that you have chosen us for your care. Please know that regardless of who you are or why you came to us, you are welcome here.

This Agreement contains important information about our professional services and business policies, and information required by the Health Insurance Portability and Accountability Act (HIPAA).

Please read this document carefully and address any concerns or questions to your clinician. When you sign the signature page, it will represent an agreement between you and Cognia Health PLLC.

EVALUATIONS AND TREATMENT

Initial Psychiatric Evaluations

The first step of treatment is the initial evaluation. This evaluation may require multiple sessions to establish the goals of treatment (your treatment plan). One of the goals of these initial sessions is for you and your provider to decide if this is a good pairing to provide the services you need. Thus, completing an initial evaluation is not a guarantee of a medication prescription or continued treatment with this provider. If continuing treatment at Cognia Health is not recommended, the clinician completing the evaluation will discuss the reasons and options for treatment.

Before attending any appointments at Cognia Health, it will be required to complete any pre-evaluation forms or documents, including this agreement. Without a documented consent to receive psychiatric care with a Cognia Health provider or being informed about the practice’s policies, we are not able to provide you with any medical services.

Follow up Appointments

After the initial treatment evaluation(s), there are typically two different kinds of appointments. If medications are recommended, medication management appointments typically lasting 20 to 30 minutes will be scheduled to monitor your clinical status and response to treatment. These appointments will be required to continue prescribed medications. If medications are not recommended, consultation appointments for other medical reasons may still be appropriate. Attending appointments and following through on recommendations is vital for you to have your best outcome.

OVERVIEW OF PSYCHIATRIC SERVICES

Psychiatric Care

Psychiatric treatment involves diagnostic assessments, education, medication management, and supportive and educational therapy. The initial assessment is usually completed in the first or second appointment and serves to guide treatment recommendations. On occasion, it may not be possible to complete the intake until outside records or additional specific evaluations are obtained. Upon completion of the assessment, the clinician will explain the recommendations and answer any questions.

Your provider will recommend the time frame for follow up appointments based on your specific treatment and clinical concerns. This time frame reflects the frequency of assessment required to provide appropriate care. Thus, if you need to cancel an appointment, it will be important to reschedule in a timely manner. If your medication provider determines that there has been insufficient follow-up to safely continue the current medication(s), they may decline to renew a medication or provide only a partial refill pending attending an appointment.

Your provider’s priority is to provide you with services to help you reach your goals, but please remember that your clinician cannot guarantee any particular outcome. Your provider will work with you to develop a treatment plan and will regularly collaborate with you in discussing treatment progress. You have the right to agree or disagree with your provider’s recommendations. However, due to the varying nature and severity of problems and the individuality of each patient, your clinician is unable to predict the length of your therapy or to guarantee a specific outcome or result.

Psychotherapy

Psychotherapy and psychotherapeutic tools are often incorporated into every appointment. This therapeutic approach typically contributes to better patient outcomes and the combination of pharmacologic and non-pharmacologic interventions is a core philosophy at Cognia Health. We believe that medications enable and potentiate progress in psychotherapy and vice-versa.

Since psychotherapy often involves discussing problematic aspects of your life, you may experience challenging feelings such as sadness, guilt, anger, frustration, loneliness and hopelessness. However, psychotherapy has been shown to have many benefits including better relationships, solutions to specific problems, and significant reductions in feelings of distress.

In some cases, based on the initial evaluation, treatment goals, or treatment progress, among other clinical reasons, patients will be recommended or referred for psychotherapy to an outside psychotherapist that may be able to meet more frequently or sub-specialize in unique skills, among other purposes.

At Cognia Health, we try to coordinate your care to meet that goal wherever possible. Thus, you are encouraged, if comfortable, to complete a Release of Information form that would enable us to communicate and collaborate with outside clinicians.

Medication Refills

Cognia Health will make every effort to ensure that you have enough medication to cover you until your next scheduled appointment by prescribing an appropriate number of refills at your visit. Please be aware that controlled substances have specific regulations regarding their use and more frequent visits may be required since they do not allow for a refill element in their prescription. Some examples of controlled substances are stimulants like Adderall, Ritalin, Vyvanse; or Benzodiazepines like Klonopin or Xanax.

If something is accidentally missed by Cognia Health and needs to be refilled between appointments, you will not be charged by Cognia Health for the time involved. However, if you run out of medication due to missing/cancelling an appointment or neglecting to reschedule, you will be billed for any refills that are requested between appointments. We prefer that patients request their own refills and reserve the right to ignore pharmacy-generated requests as these are often sent in error. Please allow up to 2 business days for refill requests. Also, we strongly encourage not to wait until you are out of medication to request a refill.

Controlled Substances

Prescription medications are classified as either controlled or non-controlled substances. Most psychiatric medications fall under the non-controlled category. However, some psychiatric prescriptions like stimulants or benzodiazepines are classified as controlled substances regulated by the Drug Enforcement Administration (DEA) due to their potential for misuse or dependance. Some examples of controlled substances are stimulants like Adderall, Ritalin, Vyvanse; or Benzodiazepines like Klonopin or Xanax.

At Cognia Health, controlled substances are prescribed sparingly in an effort to keep you safe, and only in situations where the possible therapeutic benefits outweigh potential harm. In most cases where a controlled substance is prescribed, patients will be required to complete an additional agreement describing possible risks and specific indications including but not limited to taking any controlled medication as prescribed and not self-adjusting the dose or administration frequency, seeking additional controlled substances prescriptions for the same or similar drugs used at Cognia Health from other prescribers, and/or sharing or selling the medication.

Patients may also be asked to obtain either a urine or blood drug screen prior to any controlled substance being prescribed. Random such testing is also obtained at different intervals throughout treatment. Completion of such screens is ultimately the personal and financial responsibility of the patient these medications are prescribed for. Such screens help to determine the presence or absence of controlled substances. Testing negative for prescribed controlled substances or positive for additional controlled or illicit substances not prescribed by our providers can be considered a breach of the controlled substance policy and grounds for immediate discontinuation of the drug prescribed and/or from the practice.

Monitoring of controlled substances is maintained through the Prescription Drug Monitoring Program. As is required from providers, we obtain, review, and monitor Prescription Drug Monitoring Programs in various states. This includes monitoring for multiple controlled substances prescriptions, multiple providers, usage of multiple pharmacies, and any activity that could be suspicious for misuse. We work closely with pharmacies, as they will often call us if they suspect misuse.

Since the beginning Public Health Emergency in the year 2020 due to the COVID-19 pandemic in the United States, the Ryan Haight Act, which prevents the Telehealth prescription of controlled substances without a previous in-person appointment, has been waived. Currently, there have been no updates from the DEA or other relevant governmental agencies describing future details. However, if in-person appointments are required once every 12-24 months to continue a controlled substance treatment, your clinician may need to discuss future plans and accommodations to continue your treatment. We are committed and hopeful that you and your provider will design an optimal adjustment to continue your care.

Disability or Family and Medical Leave Act

Disability-related paperwork or Medical Leave-related paperwork is not offered during initial consultations at Cognia Health. However, Medical Leave-related paperwork may be offered after meeting for at least 3-4 appointments, if appropriate. Additionally, you may request your clinician provide a short, personalized letter that documents a summary of your psychiatric care at Cognia Health.

REFERRALS OR TERMINATION OF TREATMENT

The length of your treatment and the timing of the eventual termination of your treatment depend on the specifics of your treatment plan and the progress you achieve. It is a good idea to plan for your termination, in collaboration with your provider. Your clinician will discuss a plan for termination with you as you approach the completion of your treatment goals.

However, you may request to end or transfer treatment to another institution at any time. We encourage you to discuss this choice with your treating clinician in advance so that you can be assured of having as much pertinent information as possible when you make your decision. We can offer referrals to assist you to find another provider who will help you continue your treatment.

As mentioned above, an initial decision to continue treatment with the clinician who completed an evaluation is not a guarantee that clinician will be able to continue to provide services under all circumstances. If your treatment needs change, it is possible your clinician will recommend a treatment that they are not able to provide. Under these circumstances, your clinician may refer you to a second provider for adjunctive treatment, or recommend your care be transferred to a clinician or practice more appropriate to your needs.

Recommendations to transfer care typically occur when the specific treatment needs are outside our areas of expertise, treatment recommendations that may not fit the outpatient or Telehealth format, or because of patient non-adherence with treatment recommendations, appointments or financial obligations. Examples of treatment needs that may be outside our areas of expertise include but are not limited to significant substance misuse, developing medically unstable conditions, psychiatric conditions requiring frequent hospitalization, and/or emergency appointments. Non-adherence may include not following through on agreed treatment recommendations, not coming to appointments or late canceling of appointments, misusing prescription medications, declining treatment recommendations and/or referrals for treatment without providing a reasonable explanation.

For any of these reasons, as well as other ones that would compromise your treatment, if the decision is made to transfer or terminate Cognia Health treatment, your clinician will provide short-term treatment (30 days or less) while you arrange to transfer your care. Suggestions will be provided for other treatment options. Depending on the reasons for the recommendation, appointments at Cognia Health may be required during the transfer process. The time period of coverage during transfer may be shorter if the recommendation is considered urgent. If there is a concern that your situation is unstable and/or unsafe, it may not be appropriate to continue the previously established treatment during the transition period.

CANCELLATIONS AND MISSED APPOINTMENTS

We request that you provide at least 48 business hours advance notice of cancellation. Late cancellations, failure to cancel, or arriving more than 15 minutes late will result in a full fee charge to your account. In some emergency cases, this fee may be waived, such as the death or birth in the family, an accident, or serious illnesses or injuries of yourself or someone you care for. Work or travel-related conflicts will not be exceptions to this policy.

If 3 or more late, missed appointments, or cancelations happen in the year, your provider may recommend transferring your care outside of Cognia Health. No refills will be called in until the provider sees you.

There is usually an automated courtesy reminder email two days ahead of appointments. However, these reminders are not guaranteed and do not alter your responsibility to attend or cancel appointments you have made.

You may have more than one follow-up appointment scheduled. If you change one appointment, please do not assume we will cancel any other appointments. Cancellations occur only following a specific request. Please understand that clinicians usually have very full schedules, and it may be difficult to reschedule your appointment at a time that is convenient for you.

This policy is necessary because a time commitment is made to you and is held exclusively for you. Cognia Health only schedules one patient per time slot and does not double book. Therefore, late cancellations, missed, or late attendance will be charged the full fee and must be paid prior to rescheduling. When you cancel or reschedule less than 48 business hours prior to your appointment, or do not show up for your appointment, you prevent someone else from seeking treatment. You also place a financial burden on the practice. As a small practice, we can’t stay in business and provide care if patients repetitively miss, reschedule at the last minute, or continuously cancel appointments. Most importantly, the best and optimal care that we aim to provide you is usually significantly impacted by inconsistent attendance. We hope that you understand why this policy exists.

CONTACTING YOUR PROVIDER

Emergencies

Cognia Health does not provide on-call, emergency, or crisis services. If you or a loved one are experiencing a life-threatening or mental health emergency, please call 911 or the National Suicide & Crisis Lifeline at 988. In such situations, you may also go to the nearest emergency room.

If you think that your concern poses any risk to you that is time sensitive, including a medication reaction, or if you think you might require urgent psychiatric inpatient assistance or hospitalization, please do not wait for a response from your clinician. Call 911 for transportation to your local emergency room.

Established Patients

Current or established patients are highly encouraged to contact their provider through the Direct Message feature in the Luminello Electronic Health Record (EHR). This way of communication is the safest, most direct, and easiest method to keep track of communication and document.

New Patients or General Public

Prospective or new patients are welcome to email Cognia Health directly but encouraged to describe their consultation motives minimally, in the effort to protect their privacy. Cognia Health utilizes secure and additional cyber security layers such as Google’s Workspace features, Paubox email encryption, plus any recommendations given by our Cyber Security Insurance provider. However, if the interested individual decides to schedule an appointment at Cognia Health, they will be invited to the Luminello EHR to continue further communications in an even safer way.

General Communications

Messages or any general communications will be typically replied to within 2 business days.

Communications outside of scheduled appointments are meant for a brief, important, and simple purpose that can be reasonably addressed in 5 minutes or less. Your Cognia Health provider prefers to make all important clinical decisions during an appointment. If your message requests a medication change or a clinical decision, you will likely be asked to schedule an appointment to discuss it further so that it may be given full attention. Furthermore, if a message or phone call involves a task that requires a time significantly over the 5-minute framework, you may also be required to pay an associated fee.

BILLING AND PAYMENTS

Cognia Health is a private pay, out-of-network (OON) practice, which means that your provider is not-in-network with any insurance companies nor Employee Assistance Programs (EAP). Therefore, payment is due at the time of each appointment in full and should be automatically charged to your preferred credit card safely stored in the Luminello EHR and processed by Bluefin. Cognia Health does not have complete access to your credit card information securely stored and processed by Luminello and Bluefin. Your provider can only see the last 4 digits of your credit card and the expiration date. No other credit card information is visible to anyone at Cognia Health.

Your payment information must be added before the initial appointment. If you do not have a credit card on file or your card is declined, your provider will call or email you to discuss possible adjustments to your payment methods. Your provider may discontinue treatment if there are unpaid balances.

By signing this agreement, you authorize Cognia Health to charge your card for any received services and understand this authorization will remain in effect until the expiration of the credit card account in which it will be updated. You may also revoke this agreement by submitting a written request. Also, if a charge is processed to the card on file and declined, the patient will be billed for any fee(s) associated with the decline of the credit card. Additionally, you acknowledge that you are an authorized user on the card being used or have been given permission to utilize such card. If a fraudulent accusation results as a result of using this card,  Cognia Health will cooperate with the authorities to prosecute any illegal activity. Please make sure you have the permission of the cardholder to use the credit card on file.

Under circumstances of unusual and demonstrated financial hardship, we can sometimes temporarily continue services for a reduced or waived fee. If an account is more than 60 days past due, without an established payment agreement, the agreement may be remanded to a collections agency or small claims court. If such legal action is necessary, its costs are typically included in the claim.

No Surprises Act and Good Faith Estimate

Health care providers are required to give new, prospective, or established patients who are uninsured, or self-pay, a good faith estimate of costs for services that they provide. While it is not possible for a provider to know, in advance, how many sessions may be necessary or appropriate for a given person, this form provides an estimate of the cost of services rendered that are provided per session. Your total cost of services will depend upon the number of clinical appointments you attend, your individual circumstances, and the type and/or amount of services that are provided to you. Your provider will collaborate with you throughout your treatment to determine how many sessions and/or services you may need to receive the greatest benefit based on your diagnosis(es)/presenting clinical concerns. This estimate is not a contract and does not obligate you to obtain any services from Cognia Health, nor does it include any services rendered to you that are not identified here.

This Good Faith Estimate is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of appointments. Many patients will attend one visit every four to twelve weeks, but the frequency of visits that are appropriate in your case may be more or less, depending upon your needs. The number of appointments that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with your provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

The amount below is only an estimate, and it is not an offer or contract for services. This estimate shows the full estimated costs of the items or services listed. This means that the final cost of services may be different than this estimate.

Good Faith Estimates:

·      Initial Psychiatric Evaluation – 60 minutes (CPT 90792, 99203, 99204, 99205): $300

·      Initial Psychiatric Evaluation – 90 minutes (CPT 99205+99417): $450

·      Follow-up Appointment – 20-30 minutes (CPT 99213, 99214): $150

·      Follow-up Appointment – 31-60 minutes (CPT 99214, 99214 + 90833, 99215, 99215 + 90833, 99215+99417): $300

·      Prescriptions outside of an appointment: $30

·      Communications that require tasks longer than 5 minutes and up to 15 minutes: $50-$75

·      Communications that require tasks longer than 5 minutes and up to 30 minutes: $150

·      Paperwork or any other form of documentation not completed during the appointment: $50 per page

·      Missed appointments or cancellations less than 48 hours in advance will be charged in full

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. In those cases, we recommend that you contact your clinician to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. 

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises. Most importantly, starting a dispute will not adversely affect the quality of health care services at Cognia Health.

With my electronic signature, I am agreeing to receive services at Cognia Health and consenting of my own free will and am not being coerced or pressured. I understand that I may be giving up some consumer billing protections under federal law, and that I will get a bill for the full charges for these items and services and pay out-of-network cost-sharing under my health plan. Also, I recognize I was given a written notice explaining that Cognia Health isn’t in my health plan’s network, the estimated cost of services, and what I may owe. Furthermore, I fully and completely understand that some or all amounts I pay might not count toward my health plan’s deductible or out-of-pocket limit. I can end this agreement by notifying Cognia Health in writing before getting services.

You don’t have to sign this agreement. But if you don’t sign, Cognia Health will not be able to provide psychiatric services. To the extent you are insured, you can choose to get care from a provider or facility in your health plan’s network.

HEALTH INSURANCES AND OUT OF NETWORK BENEFITS

Cognia Health is not in network with any insurance companies nor EAPs. As such, you can choose to keep your information private and control who has access to your psychiatric record. Payment is due at the time of service, regardless of insurance.

Benefits of Private Pay

There are many benefits for patients who choose private pay therapy instead of using insurance, including:

·      Freedom to choose a clinician who is the best fit for your needs

·      Freedom for you and your provider to determine the course and length of treatment

·      Increased confidentiality for you and your clinician that prevents needing to share your medical information with an insurance company

·      No restrictions on Telehealth

·      Continuing to work with the same provider even if your health insurance changes

Out of Network Reimbursements and Superbills

At Cognia Health, we are happy to provide you with Superbills which are unique invoices with relevant medical codes that you can submit to your insurance carrier for complete or partial reimbursement for our services.

If you plan to file a claim with your insurance carrier, it is recommended that you contact your insurance carrier in advance to verify your out of network benefits and find out how your insurance may reimburse you for Cognia Health Services. Most health insurances offer reasonable out-of-network benefits and should be able to assist you with the reimbursement process. However, it is not possible to submit your claims for reimbursement to Medicare or Medicaid.

It is your responsibility to understand your insurance plan and seek information about the company’s reimbursement process. You may find answers to these questions in your insurance Summary of Benefits or your insurance company’s website. We recommend calling your insurance company to verify your benefits. You can usually find this phone number on the back of your insurance card. Cognia Health cannot and does not guarantee insurance reimbursement of any kind because those are services provided by the insurance carrier.

Recommended questions to ask your insurance company about out-of-network benefits:

• Do I have out-of-network outpatient mental health benefits?

• If I have out-of-network outpatient mental health benefits, what percentage or dollar amount will I be reimbursed for psychiatric consults/appointments?

• Is Telehealth/Telemedicine/Telepsychiatry covered by out-of-network benefits?

• Do I have an annual deductible? If so, how much is it, and how much of my deductible has been met for this year?

• If I have a deductible, will I need to pay out of pocket for the out-of-network psychiatric appointments until that deductible has been met? After the deductible has been met, what percentage or dollar amount will I be reimbursed for out-of-network psychiatric appointments?

• What documentation do I need to submit to receive out-of-network psychiatric appointments reimbursements?

• Do I need a referral from an in-network provider to see an out-of-network provider?

Help Submitting OON Insurance Claims

If you need help submitting claims, there’s a service called Reimbursify (https://reimbursify.com) that will submit the insurance reimbursement paperwork for you. The first claim is free, and then they charge $1.99 to $2.99 per claim.

Medicare and Medicaid

Cognia Health is not contracted with Medicare or Medicaid (Apple Health in Washington State). As mentioned above, Medicare and Medicaid do not offer out-of-network benefits.

Additionally, patients who have Medicare insurance policies must sign the federally-mandated “Private Contract” to receive services paid privately.

CLINICAL RECORDS AND CONFIDENTIALITY

Medical records include information about your reasons for seeking evaluation/medication or other services, a description of the ways in which your problem impacts your life, your diagnosis, the goals that were 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, and any reports that have been sent to anyone. The laws and standards of our professional providers require that we keep Protected Health Information (PHI) about you in your Medical Record. Typical use of these records includes documentation of the treatment process, assistance for the provider in treatment planning and overview, or communication with a collaborating provider. Furthermore, typical disclosure of treatment records occurs with the patient’s written consent to communicate with a Primary Care Provider or another mental health professional outside Cognia Health.

Signing this agreement will represent or acknowledge that you were provided with this information and HIPAA regulations which may be revoked, in writing, at any time. Additional information regarding health information can be found at www.hhs.gov./ocr/privacy.

Patient Rights

HIPAA provides you with several new or expanded rights with regard to your Medical Records and disclosures of PHI. These rights include receiving ethical and confidential treatment without discrimination, requesting that we amend your record; requesting restrictions on what information from your Medical Records is disclosed to others; requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized; determining the location to which PHI disclosures are sent; being informed of a breach of unsecured PHI, having the right to restrict certain disclosures of PHI to a health plan if the patient pays out of pocket in full for the health care service, having the right to choose someone to act for you, having any complaints you make about policies and procedures recorded in your records, having the right to choose not to receive service with us and terminate or transfer your care, and the right to a paper copy of this Agreement. We are happy to discuss any of these rights with you.

We are required to notify you by first class mail or by e-mail of any breach of your PHI as soon as possible, but in any event, no later than 60 days after we discover the breach. The notice will give you the following information: a short description of what happened, the date of the breach and the date it was discovered; the steps you should take to protect yourself from potential harm from the breach; the steps we are taking to investigate the breach, mitigate losses, and protect against further breaches; and contact information where you can ask questions and get additional information. If the breach involves 10 or more patients whose contact information is out of date, we will post a notice of the breach on our website.

Copying or Reviewing Your Medical Record

Except in unusual circumstances that involve danger to yourself and/or others who may be named in the record, you may examine and/or receive a copy of your Medical Record. We require that the request be made in writing, and strongly recommend that you initially review them in the presence of your provider or have them forwarded to another mental health professional so you can discuss the contents. These are professional records meant to facilitate your treatment rather than to represent a comprehensive summary of all issues you reviewed; they can be misunderstood by untrained readers.

HIPAA rules also require that we notify patients that they have the right to opt out of receiving fundraising and/or marketing solicitations and that we will not sell a patient’s health information without his/her express consent – however, Cognia Health does not send out such marketing requests or seek to sell recorded information.

Limits and Exceptions to Confidentiality

The law protects the privacy of all communications between a patient and medical provider. In most situations, communications between you and your clinician will be held in strict confidence unless you provide written permission to release information about your treatment, signing a written authorization form that meets certain legal requirements imposed by HIPAA. There are many exceptions to the requirement for written authorization that typically relate to treatment, payment, or operations. These include, but are not limited to:

·      Communication with other professionals involved in your care in urgent cases where completing a Release of Information form may not be possible

·      Written correspondence that is delivered to the patient rather than a third party

·      Communication with family members in some circumstances

·      Communication with other individuals who are involved in your treatment, either directly or financially

·      Professional consultation regarding your treatment

·      Administrative communication within Cognia Health and with our EHR or billing company

·      Reminders directed to the email address you provided

·      Other actions to facilitate payment of charges: this includes billing the identified guarantor, phone calls and letters to discuss billing or payment issues, and provision of information to third parties to obtain payment when requests for payment have not been addressed.

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

·      Threat to safety of self or others: If a clinician believes that a patient presents an imminent danger to the health and safety of himself/herself or someone else, the clinician may be required to disclose information in order to take protective actions, including initiating hospitalization, warning the potential victim, if identifiable, and/or calling the police.

·      Abuse or neglect of a child or vulnerable adult: Washington State law requires that every practitioner report suspected child or vulnerable adult abuse and/or neglect to the Washington Department of Social and Health Services (APS) and the appropriate law enforcement agency.

·      Court proceedings: Release of your information for a court proceeding requires your authorization or a court order.

·      Lawsuit: If you are involved in a lawsuit or a dispute, we may disclose PHI in response to a court or administrative order. We also may disclose PHI in response to a subpoena, discovery request, or other legal process from someone else involved in the dispute, but only if efforts have been made to tell you about the request or to get an order protecting the information requested. We may also use or disclose your PHI to defend Cognia Health if sued by a patient.

·      Law Enforcement. We may release PHI if asked by a law enforcement officer for the following reasons: in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime; about a death we believe may be the result of criminal conduct; about criminal conduct on our premises; and in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

·      National Security. We may release PHI to authorized federal officials for national security activities authorized by law. For example, we may disclose PHI to those officials so they may protect the President.

·      Coroners, Medical Examiners, and Funeral Directors. We may release PHI to a coroner, medical examiner, or funeral director so that they can carry out their duties. 

TECHNOLOGY, TELEHEALTH, AND SECURITY

Ensure that you are in a safe and private location during your appointment. If you need to join the appointment from a vehicle, make sure it is parked so you can engage in a safe manner. Appointments will not be conducted if you are driving and will need to be rescheduled.

Services delivered are required by law to take place within Washington State at the time of your appointment. If you are physically located outside Washington State at the time of an appointment, you agree to immediately notify your provider and reschedule the appointment.

Receiving Telehealth services may not be advised if you have experienced psychiatric needs that may be classified as acute or unfitting for outpatient services such as recent suicide attempt(s) (i.e., last 3 years), psychiatric hospitalization, psychotic features, severe major depression or bipolar disorder symptoms, moderate to severe alcohol or drug abuse, severe eating disorders, repeated “acute” crises (i.e., occurring once a month or more frequently), among others. In these cases, your provider may determine that Telehealth is not appropriate and recommend a referral to an in-person consultation outside of Cognia Health.

It is important to highlight that there is no guarantee that any Telehealth appointment will eliminate the need for you to see a healthcare professional in person in order for you to receive appropriate or additional treatment for any current condition.

Benefits of Telehealth

·      The ability to expand your choice of service provider.

·      More convenient provider options including location, time, no driving, etc.

·      Reduces the overall cost and time of treatment due to not having to drive to and from an office.

·      Ability to have real time monitoring and reduces the wait time for scheduling office appointments.

·      Increased availability of services to homebound patients, patient with limited mobility, and patients without convenient transportation options.

Limitations of Telehealth

·      Due to technology limitations, we may not hear all of what you are saying and may need to ask you to repeat things.

·      Technology might fail before or during the appointment. Our second line of communication will be via telephone.

·      Although every effort is made to reduce confidentiality breaches, breaches may occur for various reasons.

·      To reduce the effect of these limitations, we may ask you to describe how you are feeling, thinking, and/or acting in more detail than we would during a face-to-face session. You may also feel that you need to describe your feelings, thoughts, and/or actions in more detail than you would during a face-to-face session.

Logistics and Appointments

To connect to your appointment, you must go to our Doxy wait room at https://doxy.me/cognia. This link should also appear on the right side of the Luminello home page when you login with your appointment’s information. We expect that you are available at our scheduled time and are prepared, focused and engaged in the session. Please assure you reduce all possibilities of interruptions for the duration of our scheduled appointment.

Connection Difficulties and Backup Plan

If we lose our connection during a video session, we will call the phone number you entered in your chart to troubleshoot the reason we lost connection. If we cannot reach you, we will remain available to you during the entire course of our scheduled session. Should you contact us back and there is time left in your session, we will continue. If the reason for a connection loss (i.e., technology, battery dying, bad reception, etc.) occurs on your part, you will still be charged for the entire session. If the loss for connection is a result of something on our end, we can either complete our appointment or plan an alternate time to complete the remaining minutes of our session.

Telehealth and Emergencies

If your provider determines that the patient is presenting to the appointment with a concern, symptom, or any presentation that may be considered acute or in need of urgent care, they may recommend ending the appointment and transport to the closest emergency room. Your provider may call 911 with the intention to protect the patient’s physical integrity if coordinating the transport to an emergency room may be too challenging for the patient during the crisis situation. 

Confidentiality

All confidentiality information discussed in this document also applies to Telehealth. In other words, laws and standards of psychiatry and HIPAA policies still apply to online appointments. Thus, neither the provider nor the patient may record a medical appointment without previous consent.

We are calling you from a private location where we are the only person in the room; you also need to be in a private location where you can speak openly without being overheard or interrupted by others to protect your own confidentiality. If you choose to be in a place where there are people or others can hear you, we cannot be responsible for protecting your confidentiality. Every effort must be made on your part to protect your own confidentiality. We suggest you wear a headset to increase confidentiality and also increase the sound quality of our sessions.

Security and Confidentiality

At Cognia Health, we take cybersecurity and your right to privacy very seriously. Therefore, we have contracted services and software that meet the strictest criteria for high security, are HIPAA complaint, and offer Business Associates Agreements, including but not limited to Google Workspace, Spruce Health, Luminello, Paubox, and Doxy. Furthermore, every application containing PHI, or any other patient information, is protected by complex passwords and double verification procedures. There is no patient information stored locally at Cognia Health’s computer.

Electronic communications are encouraged and preferred over physical methods at Cognia Health. However, if we receive physical correspondence or records, the documents will be scanned and uploaded to the secure offsite storage and charts, while the original documentation is shredded. If physical correspondence must be used, we recommend writing “Confidential” on the envelope. Furthermore, Cognia Health does not possess or utilize physical fax machines. All fax communications are securely administered via e-fax through Spruce Health.

Additionally, Cognia Health has hired Cyber Liability Insurance services to further increase and protect security measures for Telehealth services. These services include 24/7 security monitoring, automated threat and intelligence alerts, DDoS mitigation, security benchmarking, employee training, and patch reminders.

Agreement

Signing this agreement will represent or acknowledge that you were provided with information about Telehealth details and potential risks, which may be revoked, in writing, at any time. Additionally, signing this agreement represents your agreement to participate in Telehealth appointments and other healthcare-related information exchanges with your mental health care provider. This means that you authorize information related to your health to be electronically transmitted in the form of images and data through an interactive video connection to and from the above-named provider and other persons involved in your health care.

By signing this agreement, you also consent that you understand that you may withdraw your permission at any time prior to the Telehealth appointment. You also understand that you may interrupt the Telehealth appointment at any time, knowing that the clinician involved in the appointment will be unable to provide treatment or services at that time due to the videocall being interrupted.

Additionally, signing this agreement will also represent that you are using your own equipment to communicate and not equipment owned by another, and specifically not using your employer’s computer or network. Information entered into an employer’s computer can be considered by the courts to belong to the employer and your privacy may thus be compromised.

Lastly, by signing this agreement you acknowledge all the efforts Cognia Health has put in place to minimize possible cyber security threats and agree to unconditionally release, hold harmless, indemnify and discharge Cognia Health and its employees from any and all liability having its source in, arising from, or in connection with your participation in Telehealth. This includes, but is not limited to, any data breach caused by your or your provider’s failure to either secure the technology devices or to ensure that the session environments were secured. It is also your responsibility and the responsibility of your provider to ensure that the communications cannot be overheard.

PARTICIPATION IN LEGAL PROCEEDINGS

Cognia Health providers reserve the right not to participate in legal proceedings. If a provider agrees to participate, the specific limitations and fees will be established in writing in advance of providing the service.

PROVIDER ON EXTENDED OUT OF OFFICE TIME

If your Cognia Health provider is on a temporary but extended out of office time, you will be temporarily under a different provider’s care until the original clinician is back. The temporary backup provider should take over your clinical needs, including your medication prescriptions. Furthermore, the temporary backup provider will operate under a signed HIPAA binding contract that applies all the legal and confidentiality information discussed in this document.

CHANGES TO THE TERMS OF THIS NOTICE

This Notice of Privacy Practices is stated at the beginning, effective as of that date onwards, and applies to all persons who procure service from a provider at Cognia Health. We reserve the right to change the terms of this notice at any time. Any new Policies and Procedures will be effective for all PHI that we maintain at that time. We will make available a revised Policies and Procedures by sending you an electronic copy, publishing it on the Cognia Health website, sending a copy to you in the mail upon your request, or providing one to you in person.

By signing this agreement, you acknowledge that you have received and understand Cognia Health’s Policies and Procedures and will be responsible for knowing its contents in the future.

GRIEVANCES

If you have difficulty with our services, please let us know as soon as possible and direct them to us in writing. All complaints must be made in writing and should be submitted within 180 days of when you knew or should have known of the suspected violation. There will be no retaliation against you for filing a complaint.

Matias Massaro, PMHNP is the sole owner and director at Cognia Health PLLC, and can be reached at:

Phone: (206) 350-9411

Fax: (206) 207-2587

Email: matias.massaro@cogniahealth.com

NPI: 1184222143

EIN: 88-2400165

You also have the right to file a complaint with the U. S. Department of Health and Human Services:

U.S. Department of Health and Human Services

Centralized Case Management Operations

U.S. Department of Health and Human Services

200 Independence Avenue, S.W.

Room 509F HHH Bldg.

Washington, D.C. 20201

Email: OCRComplaint@hhs.gov

Portal: https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf

Thank you for the time taken to read our office policies!

Your signature indicates that you have received and read the information in this document and agree to abide by its terms during our professional relationship, that you acknowledge you understand that you have a right to receive a copy of this authorization when requested, and that any cancellation or modification of this authorization must be in writing. Otherwise, this authorization shall remain valid for the length of your treatment.

Your signature at the end of this document signifies your consent to engaging in psychiatric services with a mental health provider at Cognia Health. Thus, services will not be provided if this document is not signed.