Sean F. Kelly, Ph.D.
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Executive Coaching

Sean F. Kelly, Ph.D.

 

Boston, Massachusetts 02116

 

                                                                 
10 Woodland Road
  Beverly, Massachusetts, 01915 

617-859-0405 fax 617-859-0420

sfk@seanfkelly.com

 

Welcome to my practice. 

This section is intended to provide some useful information about my practice as well as to meet legal requirements of HIPPA.  It's the equivalent of the fine print at the end of an ad.

My Back Bay office is Suite 306, 45 Newbury Street,on the corner of Newbury and Berkeley Streets.  You will need to be buzzed into the elevator.  Many people find on-street parking at a meter.  The garage under The Common is two blocks away.  The Arlington Street T station (Green Line) is the closest public transportation. At my Beverly office, the entrance is a red door to the right of the garage.  My phone numbers are above, and I check my e-mail regularly.  When I am out of town, I check my e-mail at seanfkellyphd@gmail.com.  If you need to contact me outside of usual business hours, my cell phone is 617-792-7479.

 

I apologize for greeting you with so much contractual information, but this age of regulations and litigation require me to give you much of this verbatim.  After you have read this, please sign it to acknowledge that you have received it.  If you like, I will give you a copy to keep; you can also download it at seanfkelly.com.  These pages contain important information about psychotherapy and my clinical practice. They also contain summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides new privacy protections and new patient rights with regard to the use and disclosure of protected health information.  An explanation of HIPAA and its application to you is attached to this Agreement.  Please read this information carefully and jot down any questions you might have so that we can talk about them at our next meeting. 

 

PSYCHOLOGICAL SERVICES

The first few sessions are usually introductory and evaluative. I will be asking you many questions about the reasons you are seeking therapy and the history of your presenting concerns. By the end of the evaluation, I will be able to offer you my clinical impressions and treatment recommendations. You should evaluate this information along with your own impression of whether you feel comfortable working with me. Therapy involves a large commitment of time, money, and energy, so you should be very careful about the therapist you select. If you have questions about my procedures, we can discuss them whenever they arise. If any doubts persist, I will be happy to help you set up a meeting with another mental health professional for a second opinion.

 

Psychotherapy has been shown to have many benefits for people who utilize it.  Therapy can lead to better relationships, increased coping skills and physical wellbeing, solutions to specific problems, and a significant reduction in feelings of distress.  Besides the benefits of therapy, it can also involve risks.  Since therapy can include discussing unpleasant events and aspects of one’s life, you may also experience some uncomfortable feelings.  There is no guarantee that psychotherapy will always be effective; however, if we regularly focus on your goals and presenting concerns, a favorable outcome will likely result.

 

There are some policies pertaining to my practice that I need to clarify for you.  These include: fees, insurance billing, cancelled appointments, emergency availability, limits of confidentiality, record keeping, and your patient rights.

 

PROFESSIONAL FEES

 


My customary fee for a 50-minute session is $275.00. You will be expected to pay for each session at the end of each month, unless we agree otherwise or unless you have insurance coverage that requires another arrangement.  If other services are necessary for your care or requested by you, such as report writing, preparation of records, or consultation with other professionals, a fee based on my hourly rate will apply. If you choose to use your insurance, I will do my best to get them to pay for your visits.  If or when your insurance benefits end, the above amount will be billed to you unless some other arrangement has been made.  Insurers regularly note that authorization of services is not a guarantee of payment.  Ultimately, you are the one responsible for your bill. 

 


INSURANCE BILLING

 


Insurance can be a useful financial support to your therapy.  You should be certain to obtain prior authorization, if necessary; obtaining such authorization is your responsibility.  If you fail to obtain it, charges incurred are your responsibility. 

 


You should be aware that your contract with your health insurance company requires that I provide it with information relevant to the services that I provide to you. For example, I am required to provide a clinical diagnosis. Also, for plans that require authorization for extended benefits, I am required to provide clinical information and/or a treatment update.  In such situations, I will make every effort to release only the minimum information about you that is necessary for the purpose requested. This information will become part of your file with the insurance company.  Although all insurance companies claim to keep such information confidential, in some cases, they have been known to share this information with a national medical information databank. I will provide you with a copy of any report I submit, if you request it. By signing this Agreement, you agree that I can provide requested information to your carrier unless you direct me not to do so. It is important to remember that you always have the right to pay for my services yourself to avoid the potential problems described above.

 


CANCELLATION POLICY

 


Your appointment time is reserved for you exclusively.  If you cancel at the last minute or do not show up for your appointment, no one else can be seen during your time.  Appointments may be charged unless cancelled 24 hours before the appointed time.  Cancelled or missed appointments cannot be charged to insurance companies as they will not pay for any services which are not “face-to-face”.  Thus, you are responsible for this charge.  The charge for a late cancellation is $100, for a "no show" $125.

 


EMERGENCIES

 


If an emergency or crisis should arise, it may not always be possible for me to meet with you immediately.  I will, however, make every effort to be available by phone as soon as possible and we can schedule an appointment at the earliest available time.  In the event of an emergency, you may call me on my cell phone, 617-742-2939.  If you cannot reach me and/or cannot wait for me to return your call, you should call the emergency service numbers in your telephone book or go to your nearest hospital emergency room.

 


LIMITS ON CONFIDENTIALITY

 


Confidentiality is an important element of psychotherapy.  The law protects the privacy of all communication between a patient and a psychologist, and in most situations, information about your treatment can only be released with written Authorization from you. There are other situations that require only that you provide written, advance consent.  Your signature on this Agreement provides consent for those activities, as follows:

 

  • I may on occasion find it helpful to consult other professionals about your care. In doing so, names and identifying information are not disclosed. These other professionals are also legally bound to keep all information confidential. If you do not object, I will not inform you of these consultations when they occur unless I feel that it is important to our work together.

 

·         Disclosures required by health insurers for payment and/or authorization of services.

 

·         In the event that you leave therapy and have an outstanding balance after a reasonable period of time has elapsed, your account may be turned over to a lawyer for collection.  Under these circumstances, certain demographic information about you can be released.

 

 

There are some situations where I am permitted or required to disclose information without either consent or Authorization:

 

·         In some legal proceedings in which your emotional state is an important consideration (i.e., child custody cases, disability claims), a judge may order my records or testimony.  If you are involved in or contemplating litigation, you should consult with your attorney to determine whether a court would be likely to order me to disclose information.

 

·         If a government agency is requesting the information for health oversight activities, I may be required to provide it for them.

 

·         If you file a worker’s compensation claim, I must provide necessary information, including a copy of your record, to your employer, the insurer or the Department of Worker’s Compensation. 

 

·         If you file a complaint or lawsuit against me, I may disclose relevant information regarding your treatment in order to defend myself.

 

 

There are some situations in which I am legally obligated to take actions, which are necessary to protect an individual from harm. These situations include:

 

§  If I have reasonable cause to believe that a child under age 18 is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child's health or welfare (including sexual abuse), or from neglect (including malnutrition), the law requires that I file a report with the Department of Social Services. Once such a report is filed, I may be required to provide additional information.

 

§  If I have reason to believe that an elderly individual is suffering from or has died as a result of abuse (including financial exploitation) the law requires that I report to the Department of Elder Affairs. If I have reason to believe that a mentally or physically disabled individual is suffering from or has died as result of a reportable condition (which is defined as a serious physical or emotional injury resulting from abuse and includes non-consensual sexual activity), the law requires that I report to the Disabled Persons Protection Commission and/or other appropriate agencies. Once such a report is filed, I may be required to provide additional information.  I need not report abuse if a disabled person invokes the psychotherapist-patient privilege to maintain confidential communications.

 

§  If you communicate an immediate threat of serious physical harm to an identifiable victim or if you have a history of violence and the apparent intent and ability to carry out the threat, I may be required to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for you.

 

§  If you indicate a clear and present danger to hurt yourself and refuse to accept further appropriate care, I may be obligated to seek hospitalization for you or to contact family members or others who can provide protection to you.

 


Please discuss with me now or in the future any questions or concerns you may have about the situations I have included here.

 


PROFESSIONAL RECORDS

 


You should be aware that, pursuant to HIPAA, I keep protected health information about you in two sets of professional records. One set constitutes your Clinical Record. It includes information collected from the evaluation meeting(s), any past treatment records that I received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. You may examine and/or receive a copy of your Clinical Record if you request it in writing unless I believe that access would endanger you. In those situations, you have a right to a summary and to have your record sent to another mental health provider or your attorney. Because these are professional records, they can be misinterpreted. For this reason, I recommend that you initially review them in my presence, or have them forwarded to another mental health professional so you can discuss the contents.

 


In addition, I also keep a set of Psychotherapy Notes. These notes are for my own use and are designed to assist me in providing you with the best treatment. While the contents of Psychotherapy Notes vary from client to client, they can include the contents of our conversations, my analysis of those conversations, and how they impact on your therapy. They also contain particularly sensitive information that you may reveal to me that is not required to be included in your Clinical record. These Psychotherapy Notes are kept separate from your Clinical Record. While insurance companies can request and receive a copy of your Clinical Record, they cannot receive a copy of your Psychotherapy Notes without your signed, written Authorization. Insurance companies cannot require your Authorization as a condition of coverage nor penalize you in any way for your refusal.  You may examine and/or receive a copy of your Psychotherapy Notes unless I believe that it would adversely and significantly affect your well-being, in which case you have a right to a summary and to have your record sent to another mental health provider or your attorney.

 


PATIENT RIGHTS

 


HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of protected health information. These rights include requesting that I amend your record; requesting restrictions on what information from your Clinical Record is disclosed to others; requesting an accounting of disclosures of protected health information that you have neither consented to nor authorized; determining the location to which protected information disclosures are sent; documenting any complaints you make about my policies and procedures; and the right to a paper copy of this Agreement, the attached Notice form, and my privacy policies and procedures. I am happy to discuss any of these rights with you.

 


The law requires that I obtain your signature acknowledging that I have provided you with this information at the end of this session. Although these documents are long and complex, it is important that you read them carefully before our next session. We can discuss any questions you have about the procedures at that time. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time.  That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process claims made under your policy; or if you have not satisfied any financial obligations you have incurred. 

Sean F. Kelly, Ph.D.

617-742-2939 fax 617-742-3327

sfk@SeanFKelly.com

                                                                       

                                                                       

You may find communication between your psychologist and your primary care physician (PCP), other health care provider, or other professional to be important in order to ensure comprehensive, coordinated quality health care. This form will allow me to share protected health information (PHI) with him or her.  This information will not be shared without your signed authorization and doing so is completely voluntary.  This PHI may include diagnosis, treatment plan and progress.

 

I, _____________________________________, d.o.b.___________________ authorize Sean F. Kelly, Ph.D., to release protected health information related to my evaluation and treatment to:

(name)_______________________________________________

 

(address)_____________________________________________

 

_____________________________________________________

 

(phone)_______________________________________________

 

Your Rights

 

You can end this authorization at any time by contacting me.

If you make a request to end this authorization, it will not include information that has been used or disclosed based on your previous permission.

You cannot be required to sign this form as a condition of treatment, payment, enrollment, or eligibility for benefits.

Information that is disclosed as a result of this authorization form may be re-disclosed by the recipient and no longer protected by law.

You do not have to agree to this request to use or disclose your information.

 

Authorization

I, the undersigned, understand that I may revoke this consent at any time except to the extent that action has been taken in reliance upon it and that in any case this consent shall expire six (6) months from the date of signature, unless another date is specified.  I have read and understand the above information and give my authorization to release any applicable information to the above named individual or institution.

 

 

Signed:________________________________________  date______________