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Terms and Policy

I am required by applicable federal and state law to maintain the privacy of your health information. I am also required to give you this Notice about my privacy practices, legal obligations, and your rights concerning your health information ("Protected Health Information" or "PHI"). I must follow the privacy practices that are described in this Notice (which may be amended from time to time).
For more information about my privacy practices, or for additional copies of this Notice, please contact me using the information listed in Section II G of this notice.


A. Permissible Uses and Disclosures without Your Written Authorization

I may use and disclose PHI without your written authorization, excluding Psychotherapy Notes as described in Section II, for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.

1. Treatment: I may use and disclose PHI in order to provide treatment to you. For example, I may use PHI to diagnose and provide counseling service to you. In addition, I may disclose PHI to other health care providers involved in your treatment.

2. Payment: I may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, I may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services.

3. Health Care Operations: I may use and disclose PHI in connection with our health care operations, including quality improvement activities, training programs, accreditation, certification, licensing or credentialing activities.

4. Required or Permitted by Law: I may use or disclose PHI when I am required or permitted to do so by law. For example, I may disclose PHI to appropriate authorities if I reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. In addition I may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. Other disclosures permitted or required by law include the following: disclosures for public health activities; health oversight activities including disclosures to state or federal agencies authorized to access PHI; disclosures to judicial and law enforcement officials in response to a court order or other lawful process; disclosures for research when approved by an institutional review board; and disclosures to military or national security agencies, coroners, medical examiners, and correctional institutions or otherwise as authorized by law

5. Notification of Appointments: I may use a phone call, voice mail message or text message to remind you of your appointments. If you do not wish to receive such reminders in this way, you must notify me in writing.

B. Uses and Disclosures Requiring Your Written Authorization

1. Psychotherapy Notes: Notes recorded by your clinician documenting the contents of a counseling session with you ("Psychotherapy Notes") will be used only by your clinician and will not otherwise be used or disclosed without your written authorization.

2. Marketing Communications: I will not use your health information for marketing communications without your written authorization.

3. Other Uses and Disclosures: Uses and disclosures other than those described in Section I.A. above will only be made with your written authorization. For example, you will need to sign an authorization form before I can send PHI to your life insurance company, to a school, or to your attorney. You may revoke any such authorization at any time.


A. Right to Inspect and Copy. You may request access to your medical record and billing records maintained by me in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, I may deny access to your records. I may charge a fee for the costs of copying and sending you any records requested. If you are a parent or legal guardian of a minor, please note that certain portions of the minor's medical record will not be accessible to you.

B. Right to Alternative Communications. You may request, and I will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.

C. Right to Request Restrictions. You have the right to request a restriction on PHI used for disclosure for treatment, payment or health care operations. You must request any such restriction in writing addressed to the Privacy Officer as indicated below. I am not required to agree to any such restriction you may request.

D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by me after April 14, 2003. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations.

E. Right to Request Amendment: You have the right to request that I amend your health information. Your request must be in writing, and it must explain why the information should be amended. I may deny your request under certain circumstances.

F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Privacy Officer at any time.

G. Questions and Complaints. If you desire further information about your privacy rights, or are concerned that I have violated your privacy rights, you may contact the Privacy Officer Heather Bokowy at 864-561-7099. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. I will not retaliate against you if you file a complaint with the Department of Health and Human Services or myself.

A. Effective Date. This Notice is effective on April 14, 2003.
B. Changes to this Notice. I may change the terms of this Notice at any time. If I change this Notice, I may make the new notice terms effective for all PHI that I maintain, including any information created or received prior to issuing the new notice. If I change this Notice, I will post the revised notice in the waiting area of my office. You may also obtain any revised notice by contacting the Privacy Officer.
( Type Full Name )
Office Policies and Information
Welcome to my counseling practice. I am honored that you have selected me to work with you at this time in your life. Please read the following information carefully. Feel free to ask any questions or discuss this with me.

Appointments: Appointments may be scheduled by speaking with me directly. An appointment typically lasts 50 minutes. If you are unable to keep your appointment, please give 24 hours notice. Otherwise you will be charged the full fee for the time reserved.

Fee: The hourly fee is $110. Payment is expected at time of service and can be made by cash or check.

Confidentiality: This notice describes how information about you may be used or disclosed and how you can get access to this information. Please review it carefully. This document may be updated without notice, so please review it each time you visit. A copy of this statement is always available upon request.

Information shared during your sessions will be held in the strictest confidence. All information revealed by you in a counseling or therapy session and most information placed in your counseling/therapy file (all medical record or other individually identifiable health information held or disclosed in any form {electronic or oral}) is considered “protected health information” by the Health Insurance Portability and Accountability Act (HIPAA). As such, your protected health information cannot be distributed to anyone else without your expressed informed and voluntary written consent or authorization. The exceptions to this are defined below. Should you wish me to confer with your physician, clergy, attorney, etc.; you will be asked to sign a “Release of Information” form.

Use or disclosure of the following protected health information does not require your consent or authorization
1. Uses and disclosures required by law – like files subpoenaed by a Judge.
2. Uses and disclosures about victims of abuse, neglect or domestic violence –
like duties to warn when someone is likely to endanger the lives of themselves or others, child sexual or physical abuse, elder abuse, etc.

3. Uses and disclosures for judicial and administrative proceedings –like a case where you are claiming malpractice or breech of ethics.

4. Uses and disclosures for health and oversight activities – like correcting records or correcting records already disclosed.

5. Uses and disclosures for law enforcement purposes –like when you claim mental health issues as a defense in a civil or criminal case.

6. Uses and disclosures for research purposes – like using client information in research; always maintaining confidentiality.

7. Uses and disclosures to avert a serious threat to health or safety – like calling Probate Court for a commitment hearing.

8. Uses and disclosures for Worker’s Compensations – like the basic information obtained in therapy/counseling as a result of your Worker’s Compensation claim.

Fees: Fees will be discussed in your first session if not before. The fee for individual, couple or family counseling is $110 per 50-minute session. Adjustment in fee payments may be discussed with me if necessary. Telephone consultations lasting longer than 10 minutes will be charges at the customary rate, proportionate to the time used. Some sessions may be scheduled for longer than 1 hour. The usual rate will be charged proportional to the time used.

Insurance: I am not a preferred provider for any insurance networks. Some insurance companies pay a portion of your bill for out of network providers. This varies greatly from plan to plan. You must check your policy or contact your company if you wish to know for sure if your plan covers my services. If you are covered by a Managed Care Plan, you must first call the company for referral and/or pre-authorization.

If you do not meet the requirements for a covered diagnosis most insurance companies will not pay for these services. In addition, you need to find out what services your company will cover i.e., individual, child, marital.

Benefits and Consequences of Psychotherapy: Persons contemplating counseling should realize that clients frequently make significant changes in their lives, People often modify their emotions, attitudes, beliefs and behaviors. Clients make changes in their marriages or other significant aspects of their lives. Because of counseling, clients may change employment, begin to feel differently about themselves and alter significant aspects of their lives. It is possible that you may initially feel worse. If this is the case please tell me so that I may be able to help you. If you have questions about the benefits and consequences of counseling, do not hesitate to discuss this with me.

In compliance with state law, you are advised that psychotherapy never includes sexual contact between a therapist and a client or any clients’ family member. Other dual relationships are also prohibited. Also you are provided with contact information for the licensing board as follows:

South Carolina Board of Examiners for Licensure of Professional Counselors, Marriage and Family Therapists and Psycho-Educational Specialists
PO Box 11329
(803) 896-4665

Professional Consultation: I routinely use the services of professional consultation. These consultants are a psychiatrist or other psychotherapeutic colleague who play an important role in effective treatment. Strict confidentiality also binds each consultant, and often it is not necessary to reveal client names. This will be discussed with you in advance and your consent will be obtained. Please be informed that there are some cases in which failure to provide consent may result in my referring you to another professional, as I may not be able to provide appropriate care without consultation.

Your signature verifies you have read this document and that you consent to treatment. It also documents that you are aware of the above information regarding confidentiality and its limits, the policies regarding fees and that treatment is not always successful and may open up unexpected emotionally sensitive areas.
( Type Full Name )
Confidentiality and Limits of Confidentiality
Heather P. Bokowy offers psychotherapeutic service in accordance with South Carolina State Law. South Carolina law requires the therapy relationship to be both professional and confidential. What is revealed in this setting is protected by legal, professional and ethical standards, such that, with a few important exceptions, all that material is confidential and not released without your written consent. In other words, I will not and cannot reveal anything about you to anyone without your written permission.

Ethically and legally, however, there exist situations in which confidentiality is limited. If there is a reasonable possibility of harming yourself or others, then I am responsible to inform others, in order to protect them and yourself. Also, the State of South Carolina requires that if there is a reasonable possibility of child abuse or elder abuse, this must be reported to the proper protective service within 36 hours. Depending on the exact circumstances, this could result in an investigation of that possibility. Any investigation would determine if the law has been broken and if any legal action is warranted.

Should you request remuneration from your insurance for part or all of you bill, then I will give you a receipt with dates of your sessions and a diagnostic code which identifies the major problem(s) being addressed in therapy. If other information is required by your insurance carrier, I will only provide such information after obtaining your consent. Confidentiality must also be broken if a government court orders the information.

I have read the above and understand that the therapeutic relationship is a private and confidential one with the exceptions noted above.
( Type Full Name )
Cancellation Policy
There are certain times when it may be necessary for you to cancel an appointment. For any reason other than illness, I require 24 hour notice. If you do not cancel with this notice please understand that you will be responsible for the full fee for that session. Please note that insurance companies will not pay for a cancelled or "no-show" appointment.

If I must cancel an appointment, I will notify you as soon as possible and will reschedule for a time that is convenient for you.
( Type Full Name )