Uses & Disclosures

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For Example: Results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by treatment team members.

Payment: Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For Example: Your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.

Law Enforcement: Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.

Other Uses & Disclosures Require Your Authorization: Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.

Individual Rights: You have certain rights under the Federal Privacy Standards.

These Include:

1. The right to request restrictions on the use & disclosure of your Protected Health Information.
2. The right to receive confidential communications concerning your medical condition & treatment.
3. The right to inspect & copy your Protected Health Information.
4. The right to amend or submit corrections to your Protected Health Information.
5. The right to receive an accounting of how & to whom your Protected Health Information has been disclosed.
6. The right to receive a printed copy of this notice.

Alison Jedrick, LCSW. Duties: We are required by law to maintain the privacy of your protected health information & to provide you with this Notice of Privacy Practices. We are also required to abide by the privacy policies & practices that are outlined in this notice.

Right to Revise Privacy Practices: As permitted by law, we reserve the right to amend or modify our privacy policies & practices. These changes in our policies & practices may be required by changes in Federal & State laws & regulations. Upon request, we will provide you with the most recently revised notice on any office visit.

The revised policies & practices will be applied to all protected health information we maintain.

Requests to Inspect Protected Health Information: You may generally inspect or copy the protected health information that we maintain. As permitted by Federal Regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting me. Your request will be reviewed & will generally be approved unless there are legal or medical reasons to deny the request.

Complaints: If you would like to submit a comment or complaint about our Privacy Practices, you can do so by sending a letter outlining your concerns to:
Alison Jedrick, LCSW.
135 W. Tisbury Lane
Pooler, GA 31322
ajedrick@yahoo.com

If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address. You will not be penalized or otherwise retaliated against for filing a compliant.

HIPAA (Health Insurance Privacy & Accountability Act) does allow us to release information to outside entities on your behalf. Example: Another medical office when making you an appointment, your insurance company when trying to get your claims paid, your pharmacy or hospital.
Effective Date: This Notice is effective on or after April 3, 2003.

Consent to Use & Disclosure of Protected Health Information (HIPAA)

Your protected health information will be used by Alison Jedrick, LCSW. or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.

You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be Used or Disclosed. You may review the notice prior to signing this consent. You may also request a copy of the Notice of Privacy Practices for your own records..

You may revoke this consent to the Use & Disclosure of your protected health information. You must revoke consent in writing. Any Use or Disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Alison Jedrick, LCSW reserves the right to modify the Privacy Practices outlined in the notice.

I have reviewed this consent form & give my permission to Alison Jedrick, LCSW to use & disclose my health information in accordance of the Federal Privacy Standards.

Welcome to therapy. Building a therapist-client relationship is dependent upon trust, openness, responsibility and respect. This document contains important information about my professional services. Please feel free to ask me questions about these services at any time.

Confidentiality: It is my goal to provide a safe and supportive environment for my clients as they participate in therapeutic services. I respect your privacy by keeping sessions confidential. Information about you is generally held in confidence by law and my policy is to never release information outside of sessions without your consent. Please be aware that state law and various court rulings require me to make a report to the proper authorities in one or more of the following circumstances:

 Suspected abuse, past or present, of a child under the age of 18 years.
 Suspected abuse of elders or dependent adults.
 Intention of serious and dangerous harm to self or others.
 When you waive your confidentiality. (For example, you waive your confidentiality when using your insurance company because your insurance company requires your information for payment or reimbursement of a claim.)
 When you voluntarily use your mental or emotional state in legal proceedings.
 Following a court order.

Additionally, if you have recently been under psychiatric and/or medical care, it may be necessary for me to consult with the treating physician for the purposes of diagnosis, treatment and continuity of care. This informed consent agreement includes your consent for me to consult with other health care professionals as needed.

Adolescents and Children: Adolescents and children in individual therapy will be
afforded confidential treatment. Because trust is an important therapeutic issue, parents will be provided with general progress information only. No other information will be given unless it is determined by the therapist to be in the child’s best interest to do so. It is also imperative that treatment of children not be terminated abruptly. By signing the consent for treatment of a minor, you are agreeing to provide me with a minimum of thirty days notification of your intent to terminate your child’s treatment, and also allow for at least two pre-termination sessions in order to adequately process the termination with the child.

Fees and Payment: My standard fee is $250 for intake sessions, $200 per individual session, and $210 for family sessions, unless modified by other arrangements. Court appearances are billed at $200 per hour from the time of entry into the building until released. Full payment for service is due at the time service is rendered. Payment is accepted in the form of cash, check, and credit card. Receipts are available upon request.
Special arrangements are made, occasionally, on an individual basis due to a specific hardship or circumstance. Check if applicable 0 In this instance, we have agreed to a modified fee of $_______. Therapy sessions are usually 50 minutes in duration. EMDR sessions are usually 90 minutes. The best results occur when appointments are regularly scheduled and consistently attended.

Returned Check Policy: There is an additional $35 fee for any check returned for non-sufficient funds.

Cancellations: If you wish to change your scheduled appointment, please provide 24 hour notice by calling (706) 224-1129. Because time has been reserved for you, you will be charged $100 for missed or cancelled appointments unless 24-hour notice is provided. (Please note that insurance companies do not pay for cancellation or no show fees.)

Insurance: It is recommended that you contact your insurance carrier to find out how much you will pay for outpatient psychotherapy treatment. The amount of payment will depend on your policy. Keep in mind that if you are utilizing insurance funds, third parties may review your medical record to obtain information about diagnosis, treatment process and prognosis for the purpose of treatment authorization, quality care management and payment for services. As a courtesy service your insurance will be billed by Alison Jedrick, LCSW and her contractor(s). However you will be required to pay all fees not covered or denied by your insurance.

Contacting Therapist: My voicemail is confidential. Please leave a message with your number, even if you think I already have it. I am able to return most calls daily or within 24 hours, but I usually cannot provide emergency treatment. I do not take telephone calls on Sundays. If you cannot reach me and you need to speak with someone immediately, please call 911 or report to the closest emergency room.

I have read, understand and agree with all of the terms and conditions stated above.

By initialing below, I understand and accept the following conditions while in treatment with Alison Jedrick, LCSW. 

"In treatment" means having a minimum of one session every three months. Unless otherwise agreed upon with Alison Jedrick, LCSW and documented, I will be discharged from care after three months of no contact. I may return to treatment any time provided my financial obligations are cleared and/or an ongoing plan is in place for payment. 

Court related matters are not covered by insurance, and are payable in the amount of $250/hour pro-rated every 15 minutes. This includes all travel and wait time. Court-related records requests are honored only with signed release of information. Affidavits and other court-related documentation may be completed free of charge during paid session times (fee-for-service only because court matters are not paid for by insurance). 

Emotional Support Animals: Letters documenting my need for an emotional support animal will only be granted for clients currently in treatment with Alison Jedrick, LCSW. Prior to being granted a request for a letter, the animal(s) in question must have been previously discussed in session as an emotional support for the client and such discussion must be documented. The animals in question must be housebroken, current on all shots, seen a veterinarian in the past 12 months current on all vaccinations, and have no history of aggressive or maladaptive behavior. A letter is good for 12 months but is null and void if requirements above are not met, or the animal begins to engage in aggressive/maladaptive behavior. Letters completed during session time are gratis. Letters requested out of session are billed at $50 with the exception of U.S. Veterans or Active Duty military, for whom 1 letter per year is gratis. The above is subject to change and is most recently updated as of 10/22/2019