Legal Documents

Information about Simple Practice, the electronic file Dr. Dillmann uses Dr. Dillmann uses an electronic record, which is cloud based, through a company called Simple Practice (). Dr. Dillmann accesses client records via a log in and password. Simple Practice creates a record, called a transaction log, of each time Dr. Dillmann logs in to her account. Dr. Dillmann has a Business Associate Agreement (BAA) with Simple Practice. Simple Practice meets all state and federal laws that govern electronic health care information. Here is some information, from their website, with regards to security & privacy: · Simple Practice meets, “HIPAA, HITRUST, NIST-CSF, PCI, ISO 27001/2, and CCPA frameworks. It includes security and privacy controls across 19 different domains, including but not limited to access control, data encryption and privacy, vulnerability management, vendor management, network protection, endpoint protection, risk management, and disaster recovery.” · With regards to, “security technology and practices…Your sensitive data is hosted in a Tier 1 secure hosting provider specializing in helping healthcare organizations achieve and maintain HIPAA and HITRUST security requirements: · Web pages and APIs are secured with 128-bit Secure Socket Layer encryption. · Our cloud infrastructure uses multi-factor authentication. · We use advanced key management and transparent data encryption. · Application level monitoring and intrusion protection. · HIPAA compliant encryption. · HIPAA compliant hosting architecture on enterprise level hardware. · HIPAA compliant system architecture with separate web and database environment. · Application and Database server isolation. · Firewall management. · Log retention with detailed audit trail. · Managed and secure backup and disaster recovery. · Managed patching, version control, and security updates.” · Simple Practice meets bank-level security, “Simple Practice takes the security of your account information seriously. Multiple layers of encryption are used to protect your data while it is stored or transmitted electronically. PCI-level controls are implemented to ensure that the information you process is equivalent or better than some financial institutions.” · The physical servers that Simple Practice uses have a back-up system and, “our platform servers are housed in a facility protected by proximity readers, biometric scanners, and security guards 24/7, 365 days a year.” · In order to be pro-active in terms of cyber security, Simple Practice, “hack[s their] own site—running thousands of tests, scanning our ports, and protecting against cross-site scripting. In addition, we partner with external security firms to assess our platform with an unbiased neutral approach.”

Limits of the Therapy Relationship, What Clients Should Know: Psychotherapy is a professional service I can provide to you. Because of the nature of therapy, our relationship has to be different from most relationships. It may differ in how long it lasts, in the topics we discuss, or in the goals of our relationship. It must also be limited to the relationship of therapist and client only. If we were to interact in any other ways, we would then have a “dual relationship,” which would not be right and may not be legal. I want to explain why having a dual relationship is not a good idea. Dual relationships can set up conflicts between my own (the therapist’s) interests and your (the client’s) best interests, and then your interests might not be put first. In order to offer all my clients the best care, my judgment needs to be unselfish and professional.

Because I am your therapist, dual relationships like these are improper: • I cannot be your supervisor, teacher, or evaluator. • I cannot have any other kind of business relationship with you besides the therapy itself. For example, I cannot employ you, lend to or borrow from you, and I will not trade or barter your services (things like tutoring, repairing, child care, etc.) or goods for therapy. • I cannot give legal, medical, financial, or any other type of professional advice. • I cannot have any kind of romantic or sexual relationship with a former or current client, or any other people close to a client.

There are important differences between therapy and friendship. As your therapist, I cannot be your friend. Friends may see you only from their personal viewpoints and experiences. A therapist’s responses to your situation are based on tested theories and methods of change. You should also know that therapists are required to keep the identity of their clients’ secret. Therefore, if we meet in a public place, I will not initiate an interaction, if you feel comfortable you are more than welcome to great me and I will respond in kind. Lastly, when our therapy is completed, I will not be able to become a friend to you like your other friends. In sum, my duty as therapist is to care for you and my other clients, but only in the professional role of therapist. Please raise any questions or concerns so we can discuss them.

Please remember that I am not available 24-hours and do not check messages while on vacation.

If you are in a life-threatening emergency: contact 9-1-1, the National Suicide Prevention Lifeline 1-800-273-TALK (1-800-273-8255), the Crisis Text Line by texting CONNECT to 741741, the San Diego County Access and Crisis Line at 1-888-724-7240 or go to an emergency room.

Client–Therapist Contact, Proper and Improper Conduct:

This has been written to help you understand what proper and improper conduct is for a therapist, and what responses are available to you as a consumer. It may raise issues that you have not considered before. However, if you are well informed, you will be better able to make sure your needs get met in therapy. Although almost all therapists are ethical people (that is, moral and law-abiding people) who care about their clients and follow professional rules and standards in their practice, there are a very few who do not consider what is best for their clients and who behave unethically. These issues apply to any mental health worker: psychologists, psychiatrists, social workers, counselors, clergy, nurses, or marriage and family therapists.

Therapist Behaviors That May Not Be OK:

There will be times in your therapy when it might be important, even if it is very uncomfortable for you and your therapist, to discuss your feelings and concerns about intimacy. In fact, such discussions may be needed if you are to benefit from your therapy. However, sexual contact is never a proper part of any education or therapy. Many caring therapists sometimes show their feelings through touch. These forms of physical contact in therapy, such as a handshake, a pat on the back, or a comforting hug, may not concern you. But you are the best judge of the effects that any touching may have on you. If your therapist engages in any type of physical contact that you do not want, tell him or her to stop, and explain how you feel about that contact. A responsible therapist will want to know about your feelings and will respect your feelings without challenging you. If your therapist makes sexual comments or touches you in a way that seems sexual to you, you are likely to feel discomfort. Trust your feelings. Do not assume that your therapist must be right if it feels wrong to you. There are warning signs that a therapist may be moving toward sexual contact with you. The therapist may start talking a lot about his or her own personal problems, giving you gifts, writing letters to you that are not about your therapy, or dwelling on the personal nature of your relationship. Or the therapist may create the idea that he or she is your only source of help by criticizing you for standing up for yourself, or by telling you how to behave with a sexual partner. A red flag should definitely go up if your therapist discusses his or her own sexual activities or sexual attraction to you. Other signs include making remarks intended to arouse sexual feelings, or forms of physical seduction, such as sexual touching. Attraction to Your Therapist: It is normal for people in therapy to develop positive feelings, such as love or affection, toward a therapist who gives them support and caring. These feelings can be strong and may sometimes take the form of sexual attraction. It can be helpful to discuss these feelings with your therapist in order to understand them. A caring, ethical therapist would never take advantage of your feelings by suggesting sexual contact in therapy or by ending therapy to have a romantic relationship with you. Though sexual feelings sometimes occur, and discussion about them is often useful, sexual contact with your therapist cannot be helpful. Sexual contact in therapy has been found to be harmful to the client in many ways, including damaging the client’s ability to trust. The harmful effects may be immediate, or they may not be felt until later. For this reason, sexual contact with clients is clearly against the rules of all professional groups of mental health workers (psychologists, psychiatrists, social workers, counselors, etc).

Actions You Can Take If You Believe That Your Therapist’s Actions Are Not OK:

Any time you feel uncomfortable about a part of your therapy, including therapist behavior that you think is improper, consider discussing this with your therapist. Your therapist should not try to make you feel guilty or stupid for asking questions, and your therapist should not try to frighten, pressure, or threaten you. If your therapist will not discuss your concerns openly or continues to behave in ways that are not OK with you, you probably have reason to be concerned. When a discussion with your therapist about these behaviors does not help, you have the right to take some further action. You may wish to find another therapist and/or file any of several types of complaints. It is important for you to make the final decision about what course of action is best for your concerns and needs.

Specific Courses of Action: Remember that you have the right to stop therapy whenever you choose. At the same time, you may also wish to make some type of complaint against the therapist who has acted improperly. If you choose to make a complaint against your therapist, the process may become long and difficult. Other clients taking such action have felt overwhelmed, angry, and discouraged. It is very important that you have support from people you can depend upon. Good sources of support might be family members, friends, support groups, a new therapist, or some type of advocate. Identifying and using good sources of support will help you feel more secure about your plan of action. You may wish to see another therapist to help you continue with your therapy, including dealing with problems resulting from the experience with the unethical therapist. It would not be unusual for you to have confusing thoughts and feelings about your experience and your previous therapist. It would also be understandable if you felt frightened about seeking, or had difficulty trusting, a new therapist. You may also want an advocate to actively help you in making and pursuing plans. Try to locate a mental health worker who has had experience with other clients who have been victims of therapist sexual misconduct. He or she will be able to understand your situation, provide you with important information, and support you in your choice of action. In addition, you may wish to participate in a support group. You may want to contact the state and/or national professional group to which your therapist belongs. These organizations have specific rules against sexual contact with clients, and each has an ethics committee that hears complaints.

Here is the contact information of some of these organizations: American Counseling Association: 1-800-347-6647 www.counseling.org American Psychiatric Association: 1-703-907-7300 www.psych.org National Association of Social Workers: 1-202-408-8600 www.socialworker.org American Psychological Association (I am a member of this association): 1-800-374-2721 www.apa.org 750 First Street, N.E. Washington, DC 20002-4242 You may also want to contact this state’s licensing board of the profession to which your therapist belongs. It has the power to take away or suspend the license of a professional found guilty of sexual misconduct.

In the state of California, psychologists are regulated by the Board of Psychology and master’s level therapists are regulated by the Board of Behavioral Sciences while psychiatrists are regulated by the Medical Board of California. Each of these Boards is within the Department of Consumer Affairs and contact information can be found by going to the Department’s website: http://www.dca.ca.gov/. The contact information for the Board of Psychology is as follows: Board of Psychology: 2005 Evergreen St. #1400 Sacramento, CA 95815 1-866-503-3221 bopmail@dca.ca.gov www.psychboard.ca.gov

This notice describes how medical

information about you may be used

and disclosed and how you can get

access to this information. Please

review it carefully and express any

questions or concerns that you may

have.

Privacy is a very important concern

for all those who come to this office.

It is also complicated, because of

the many federal and state laws and

our professional ethics. If you have

any questions, the privacy officer

(Dr. Dillmann is the privacy officer,

contact info is: 760-743-7789

info@drdillmann.com) will be happy

to help you understand these

policies and your rights.

Contents of this notice A.

Introduction: To my clients B.

What I mean by your medical

information C. Privacy and the laws

about privacy D. How your protected

health information can be used and

shared 1. Uses and disclosures with

your consent a. The basic uses and

disclosures: For treatment, payment,

and health care operations b. Other

uses and disclosures in health care

2. Uses and disclosures that require

your authorization 3. Uses and

disclosures that do not require your

consent or authorization a. When

required by law b. For law

enforcement purposes c. For public

health activities d. Relating to

decedents e. For specific

government functions f. To prevent

a serious threat to health or safety

4. Uses and disclosures where you

have an opportunity to object 5. An

accounting of disclosures I have

made E. Your rights concerning

your health information F. If you

have questions or problems

Introduction

This notice will tell you how

Dr. Dillmann handles your medical

information, how Dr. Dillmann uses

this information in this office, how it

is shared with other professionals/

organizations, and how you can see

it. Dr. Dillmann wants you to know

all of this so that you can make the

best decisions for yourself. If you

have any questions or want to know

more about anything in this notice,

please ask Dr. Dillmann, the privacy

officer, for more explanations/

details.

What is meant by your medical

information

Each time you visit Dr. Dillmann

or any doctor’s office, hospital,

clinic, or other health care provider,

information is collected about you

and your physical and mental health.

It may be information about your

past, present, or future health or

conditions, or the tests and

treatment you got from me or from

others, or about payment for health

care. The information Dr. Dillmann

collects from you is called “PHI,”

which stands for “protected health

information.” This information goes

into your medical or health care

record. In this office, your PHI is

likely to include these kinds of

information: - Your history: Things

that have happened to you your life

experiences relationships & personal

data. - Reasons you came for

treatment: Your problems,

complaints, symptoms, or needs. -

Diagnoses: These are the medical

terms for your problems or

symptoms. - A treatment plan:

This is a list of the treatments that

Dr. Dillmann thinks will best help

you. - Progress notes: Each time you

come in, Dr. Dillmann writes a note

that summarizes how you are doing,

what Dr. Dillmann notices about you,

and what you tell her. - Records

Dr. Dillmann gets from others who

have treated you or evaluated you.

- Psychological test scores, school

records, and other reports.

- Information about medications you

took or are taking. - Legal matters.

- Billing and insurance information

- There may also be other kinds of

information that go into your health

care records here. Dr. Dillmann uses

PHI for many purposes. For example:

- To plan your care and treatment. -

To decide how well treatments is

working for you. - When to talk with

other health care professionals, with

your consent, who are also treating

you. - To show that you actually

received services, which Dr.

Dillmann billed for. - For teaching

and training other health care

professionals. - For medical or

psychological research. - For public

health officials trying to improve

health care in this area of the

country. - To improve the way Dr.

Dillmann does this job by measuring

the results of therapy.

When you understand what is in

your record and what it is used for,

you can make better decisions about

who, when, and why others should

have this information. Although your

health care records are Dr.

Dillmann’s physical property, the

information within them belongs to

you. You can read your records, and

if you want a copy Dr. Dillmann can

make one for you (there may be a

charge for the costs of copying and

mailing, if you want it mailed to you).

In some very rare situations,

you cannot see all of what is in your

records. If you find anything in your

records that you think is incorrect or

believe that something important is

missing, you can ask Dr. Dillmann to

amend (add information to) your

records, although in some rare

situations Dr. Dillmann doesn’t have

to agree to do that. If you want, the

privacy officer, Dr. Dillmann, can

explain more about this.

Privacy and the laws about privacy

Dr. Dillmann is required to tell you

about privacy because of a federal

law, the Health Insurance Portability

and Accountability Act of 1996

(HIPAA). HIPAA requires Dr. Dillmann

to keep your PHI private and to give

you this notice about Dr. Dillmann’s

legal duties and privacy practices.

Dr. Dillmann will obey the rules

described in this notice. If Dr.

Dillmann changes the privacy

practices, they will apply to all the

PHI. Dr. Dillmann will also post the

new notice of privacy practices in

the office where everyone can see.

You or anyone else can also get a

copy from the privacy officer at any

time. It is also posted, here, on

Dr. Dillmann’s website at

www.drdillmann.com .

How your protected health

information can be used and shared

Except in some special

circumstances, when Dr. Dillmann

uses your PHI in this office or

discloses it to others, Dr. Dillmann

will share only the minimum

necessary PHI needed for those

other people to do their jobs.

The law gives you rights to know

about your PHI, to know how it is

used, and to have a say in how it is

shared. Dr. Dillmann primarily uses

and discloses your PHI for routine

purposes to provide for your care.

For other uses, Dr. Dillmann must tell

you about them and ask you to sign

a written authorization form.

However, the law also says that

there are some uses and disclosures

that don’t need your consent or

authorization.

1. Uses and disclosures with

your consent

After you have read this notice,

you will be asked to sign a separate

consent form to allow me to use and

share your PHI. In almost all cases

Dr. Dillmann intends to use your PHI

here or share it with other people or

organizations to provide treatment

to you, arrange for payment for

services, or some other business

functions called “health care

operations.” In other words,

Dr. Dillmann needs information

about you and your condition to

provide care to you. You have to

agree to let me collect the

information, use it, and share it to

care for you properly. Therefore, you

must sign the consent form before

Dr. Dillmann begins to treat you. If

you do not agree and consent Dr.

Dillmann cannot treat you. a. The

basic uses and disclosure: For

treatment, payment, and health care

operations For treatment. Dr.

Dillmann uses your medical

information to provide you with

psychological treatments or services.

These might include individual,

family, or group therapy

psychological, educational, or

vocational testing treatment

planning or measuring the benefits

of our services. Dr. Dillmann may

share your PHI with others who

provide or who will provide

treatment to you only with your

consent. For payment. Dr. Dillmann

may use your information to bill you,

your insurance or a third party.

Dr. Dillmann may contact your

insurance company to find out

exactly what your insurance covers.

Dr. Dillmann may have to tell them

about your diagnoses, what

treatments you have received, &

expected changes in your conditions.

Dr. Dillmann will need to tell them

about when sessions occurred, your

progress, & similar information. For

health care operations. Using or

disclosing your PHI for health care

operations goes beyond Dr.

Dillmann’s care and your payment.

For example, Dr. Dillmann may use

your PHI to see where Dr. Dillmann

can make improvements in the care

and services provided. Dr. Dillmann

may be required to supply some

information to some government

health agencies, so they can study

disorders and treatment and make

plans for services that are needed.

If such information is shared, your

name and personal information will

be removed from what Dr. Dillmann

sends. b. Other uses and disclosures

in health care

Appointment reminders. Dr. Dillmann

may use and disclose your PHI to

reschedule or remind you of

appointments for treatment or other

care. If you want Dr. Dillmann to call

or write to you only at your home or

your work, or you prefer an alternate

means for contact, Dr. Dillmann can

usually arrange that. Treatment

alternatives. Dr. Dillmann may use

and disclose your PHI to tell you

about or recommend possible

treatments or alternatives that may

be of help to you.

Other benefits and services.

Dr. Dillmann may use and disclose

your PHI to tell you about health-

related benefits or services that may

be of interest to you. Research. Dr.

Dillmann may use or share your PHI

to do research to improve

treatments—for example, comparing

two treatments for the same

disorder, to see which works better

or faster or costs less. In all cases,

your name, address, and other

personal information will be

removed from the information given

to researchers. If they need to know

who you are, Dr. Dillmann will

discuss the research project with

you, and Dr. Dillmann will not send

any information unless you sign a

special authorization form.

2. Uses and disclosures that

require your authorization

If Dr. Dillmann wants

to use your information for any

purpose besides those described

above, Dr. Dillmann needs your

permission on an authorization form.

Dr. Dillmann doesn’t expect to need

this very often. If you do allow Dr.

Dillmann to use or disclose your PHI,

you can cancel that permission in

writing at any time. Dr. Dillmann

would then stop using or disclosing

your information for that purpose.

Of course, Dr. Dillmann cannot take

back any information already

disclosed or used with your

permission.

3.Uses and disclosures that don’t

require your consent or authorization

The law lets us use and disclose

some of your PHI without your

consent or authorization in some

cases. Here are some examples of

when Dr. Dillmann might do this.

a. When required by law There are

some federal, state, or local laws

that require us to disclose PHI: -

Dr. Dillmann has to report suspected

child abuse. If you are involved in a

lawsuit or legal proceeding, and

Dr. Dillmann receives a subpoena,

discovery request, or other lawful

process, Dr. Dillmann may have to

release some of your PHI. Dr.

Dillmann will only do so after trying

to tell you about the request,

consulting your lawyer, or trying to

get a court order to protect the

information they requested. - Dr.

Dillmann has to disclose some

information to the government

agencies that check to see that

Dr. Dillmann is obeying the privacy

laws. b. For law enforcement

purposes Dr. Dillmann may release

medical information if asked to do

so by a law enforcement official to

investigate a crime or criminal. c. For

public health activities Dr. Dillmann

may disclose some of your PHI to

agencies that investigate diseases or

injuries. d. Relating to decedents Dr.

Dillmann may disclose PHI to

coroners, medical examiners, or

funeral directors, and to

organizations relating to organ, eye,

or tissue donations or transplants.

e. For specific government functions

Dr. Dillmann may disclose PHI of

military personnel and veterans to

government benefit programs

relating to eligibility and enrollment.

Dr. Dillmann may disclose your PHI

to workers’ compensation and

disability programs, to correctional

facilities if you are an inmate, or to

other government agencies for

national security reasons. f. To

prevent a serious threat to health or

safety If Dr. Dillmann comes to

believe that there is a serious threat

to your health or safety, or that of

another person or the public, Dr.

Dillmann can disclose some of your

PHI. Dr. Dillmann will only do this to

persons who can prevent the danger.

4. Uses and disclosures where you

have an opportunity to object Dr.

Dillmann will only share information

about you with your family or close

others if you complete an

authorization to release information.

Dr. Dillmann will ask you what

information you to have shared. You

can tell Dr. Dillmann what you want,

and Dr. Dillmann will honor your

wishes as long as it is not against

the law. If it is an emergency, and

Dr. Dillmann cannot ask if you

disagree, Dr. Dillmann can share

information if Dr. Dillmann believes

that it is what you would have

wanted and if Dr. Dillmann believes

it will help you. If Dr. Dillmann does

share information, in an emergency,

Dr. Dillmann will tell you as soon as

possible. If you do not approve Dr.

Dillmann will stop, as long as it is not

against the law.

5. An accounting of disclosures Dr.

Dillmann has made

When Dr. Dillmann discloses your

PHI, Dr. Dillmann will keep a record

of whom the information was share

with, what was shared and when it

was shared. You can get an

accounting (a list) of these

disclosures.

E. Your rights

concerning your health information

1. You can ask Dr. Dillmann to

communicate with you about your

health and related issues in a

particular way or at a certain place

that is more private for you. For

example, you can ask Dr. Dillmann to

call you at home, and not at work, to

schedule or cancel an appointment.

2. You have the right to ask Dr.

Dillmann to limit what is shared with

people who are involved in your care

or with payment for your care, such

as family members and friends. Dr.

Dillmann does not have to agree to

your request, but if Dr. Dillmann can

agree, Dr. Dillmann will honor it

except: when it is against the law, is

an emergency, when the information

is necessary to treat you.

3. You have the right to look at the

health information Dr. Dillmann has

about you, such as your medical and

billing records. You can get a copy

of these records, but Dr. Dillmann

may charge you. Contact the privacy

officer,

which is Dr. Dillmann, to arrange how

to see your records.

4. If you believe that the information

in your records is incorrect or

missing something important, you

can ask Dr. Dillmann to make

additions to your records to

correct the situation. You have to

make this request in writing and

send it to the privacy officer. You

must state the reasons you want to

make the changes. This information

would then be added to your file

however, the original information

will not be deleted out of your file –

rather the information you provide

will amend the file.

5. You have the right to a copy of this

notice. If Dr. Dillmann changes this

notice, Dr. Dillmann will post the new

one in the office, on the website and

you can always get a copy from the

privacy officer.

6. You have the right to file a

complaint if you believe your privacy

rights have been violated.

You can file a complaint with our

privacy officer and with U.S.

Department of Health and Human

Services Office for Civil Rights by

sending a letter to 200

Independence Avenue, S.W.,

Washington, D.C. 20201, calling

1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/

complaints/. All complaints must be

in writing. Filing a complaint will not

change the health care Dr. Dillmann

provides to you. You may have other

rights that are granted to you by the

laws of California, and these may be

the same as or different from the

rights described above. Dr. Dillmann

will be happy to discuss these

situations with you now or as they

arise. F. If you have questions or

problems If you need more

information or have questions about

the privacy practices described

above, please speak to the privacy

officer, who is Dr. Dillmann. If you

have a problem with how your PHI

has been handled, or if you believe

your privacy rights have been

violated, contact the privacy officer.

As stated above, you have the right

to file a complaint. Dr. Dillmann

pledges not to limit your care or take

any actions against you if you

complain. If you have any questions

or problems about this notice or Dr.

Dillmann’s health information privacy

policies, please contact the privacy

officer: Susanne M. Dillmann, Psy.D,

contact information is: 210 S. Juniper

St., Suite 213 Escondido, CA 92025

760-743-7789 www.drdillmann.com

For more information about

understanding HIPAA and these

privacy matters, you can visit: www.hhs.gov/ocr/privacy/hipaa/

understanding/consumers/

noticepp.html

Setting the Session Fee:

The session fee will be discussed in the first interaction, discussed and agreed upon in the first session – before you, the client, consent to treatment – and as needed throughout therapy.

Fees: My current fee range is $90 - $120 per session. I encourage you to determine a fee, within this range, that fits your income and life expenses. Payment for therapy is due at the time of service, unless otherwise agreed upon, and can be made with check or cash. If you cannot afford a session fee within this range, then I will be more than happy to provide you with referrals. Additional requested services, such as reports, summaries, legal proceedings, etc …, may be billed for. These services will be billed for based on the amount of time required to complete the task at the hourly rate of your therapy fee. Before engaging in the requested service an estimated fee will be discussed and your consent will be obtained.

Financial Difficulties and Balances: Please discuss any difficulties with timely and complete payment as soon as you are aware of the difficulty. Prompt discussion will allow for the ethical and legal resolution of the issue, for example with a payment plan, within a time frame acceptable to both parties. If you acquire a significant outstanding balance then therapy may be halted or terminated as, unless therapeutically or ethically contraindicated, a therapist has the legal right to terminate therapy if payment is not provided.

Returned Checks: On the off chance, you should have a check returned due to insufficient funds, please know that my bank charges a fee, and it is my policy to pass this fee on to you.

Cancellation Policy: You are allowed 2 late cancellations (cancelling a session less than 24 hours before the session) per calendar year. Any late cancellations after these two may be charged a $40 late cancellation fee. This fee may be applied regardless of why the late cancellation occurred. I reserve the right to waive this fee at my discretion i.e. for emergencies, unexpected illnesses or exigent life events. If a fee is charged you are expected to pay this cancellation fee before or at your next session. If you are more than 20 minutes late, without notifying me, I will assume that you are cancelling your session.

Phone Interactions: Telephone interactions lasting longer than 20 minutes may be charged your session fee. Any scheduled therapy session that occurs over the telephone will be charged the set therapy fee. Such sessions will be scheduled at my discretion as phone sessions are not a standard component of my practice.

Referrals: Referrals are welcome and financial compensation is not given for referrals.

Under the federal No Surprises Act, Section 2799B-6, Dr. Dillmann is required to provide a “Good Faith Estimate for Health Care Items and Services”, which details the expected charges for the services you are engaging in.

This estimate is to cover a 12-month period of time. Please keep in mind that this estimate is made using the information that is known at this point in time – meaning, that there may be unknown or unexpected costs that arise. If different services than the ones listed in this Good Faith Estimate are desired or needed, those will be discussed & covered by a new Good Faith Estimate.

If the difference between your bill and the Good Faith Estimate is substantial (substantial is defined as being over $400), then you have the right to dispute the bill. In addition to having the right to dispute the bill, you also have the right to contact Dr. Dillmann and discuss the fact that the billed charges are higher than the Good Faith Estimate. You can ask to have Dr. Dillmann update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. If you want to dispute the bill, you may 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 Dr. Dillmann, you will have to pay the higher amount.

To learn more about your right to a Good Faith Estimate and to get a form to start the dispute process, go to www.cms.gov/nosurprises. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. Finally, know that this Good Faith Estimate is not a contract and does not bind you to participate in the outlined services.

(What follows is a standard Good Faith Estimate, your specific Good Faith Estimate will include your unique information - such as once your name, address, your specific fee, your frequency of therapy and your exact estimated cost for a year of therapy.)

The primary service being engaged in is Psychotherapy (referred to as therapy in the remainder of this Good Faith Estimate), the relevant service code/CPT code is 90837: “Psychotherapy, 60 minutes with patient and/or family member”. At present we have agreed to engage in therapy on a weekly, bi-weekly, monthly or ad-hoc basis at an agreed upon fee of $90 - $120 per session allowing for vacations and holidays, let us assume that there will be 48 weeks of possible sessions in the next 12 months, meaning that if you continue to engage in therapy on a weekly, bi-weekly, monthly or ad-hoc basis at our agreed upon fee, you would be expected to pay $ for the next 12 months. Therefore, $ is the estimated total cost for engaging in therapy with Dr. Dillmann, for a 12 month period, this is your Good Faith Estimate.

Dr. Dillmann has an out-patient therapy office located at 210 S. Juniper St., #213 Escondido, CA 92025. Dr. Dillmann is the contact person and she can be reached at 760-743-7789 or via email at info@drdillmann.com.

Dr. Dillmann’s National Provider Identification number is: 1487728598 and her Taxpayer Identification Number is: 87-4030918.

I will treat what you tell me with great care.

My professional ethics (that is, my profession’s rules about values and moral matters) and the laws of this state prevent me from telling anyone else what you tell me unless you give me written permission. These rules and laws are the ways our society recognizes and supports the privacy of what we talk about—in other words, the confidentiality of therapy. But I cannot promise that everything you tell me will never be revealed to someone else. There are some times when the law requires me to tell things to others. There are also some other limits on our confidentiality. We need to discuss these, because I want you to understand clearly what I can and cannot keep confidential. You need to know about these rules now, so that you don’t tell me something as a secret that I cannot keep secret. If you have any questions at any time about these issues, please do not hesitate to bring them up.

1.When you or other persons are in physical danger, the law requires me to tell others about it. Specifically: a. If I come to believe that you are threatening serious harm to another person, I am required to try to protect that person. I may have to tell the person and the police, or perhaps try to have you put in a hospital. b. If you seriously threaten or act in a way that is very likely to harm yourself, I may have to seek a hospital for you, or to call on your family members or others who can help protect you. If such a situation does come up, I will fully discuss the situation with you before I do anything, unless there is a very strong reason not to. c. In an emergency where your life or health is in danger, and I cannot get your consent, I may give another professional some information to protect your life. I will try to get your permission first, and I will discuss this with you as soon as possible. d. If I believe or suspect that you are abusing a child, an elderly person, or a disabled person I must file a report with a state agency. To abuse means to neglect, hurt, or sexually molest another person. I do not have any legal power to investigate the situation to find out all the facts. The state agency will investigate. If this might be your situation, we should discuss the legal aspects in detail before you tell me anything about these topics. You may also want to talk to your lawyer. In any of these situations, I would reveal only the information that is needed to protect you or the other person.

2. In general, if you become involved in a court case or proceeding, you can prevent me from testifying in court about what you have told me. This is called privilege, and it is your choice to prevent me from testifying or to allow me to do so. However, there are some situations where a judge or court may require me to testify: a. In child custody or adoption proceedings, where your fitness as a parent is questioned or in doubt. b. In cases where your emotional or mental condition is important information for a court’s decision. c. During a malpractice case or an investigation of me or another therapist by a professional group. d. In a civil commitment hearing to decide if you will be admitted to or continued in a psychiatric hospital.

3. There are a few other things you must know about confidentiality and your treatment: a. I may sometimes consult (talk) with another professional about your treatment, however I will never share identifying information, such as your name, address, etc…. This other person is also required by professional ethics to keep your information confidential. b. I am required to keep records of your therapy, such as the summary notes I write after each session. You have a right to review these records with me and to make amendments.

4. Here is what you need to know about confidentiality in regard to third party payers and money matters: a. If you use a third party payer to pay part or all of my fees, this party will require me to provide information about your functioning in many areas of your life, your social and psychological history, and your current symptoms. I will also be required to provide a treatment plan for your problems and information on how you are doing in therapy. b. I will bill the third party payer as a courtesy to you. Although I believe the third party payer will act morally and legally, I cannot control who sees this information after it leaves my office. If this is your situation, let us fully discuss my agreement with the third party payer before we talk further.

5. Finally, here are a few other points: a. I will not record our therapy sessions on audiotape or videotape without your written permission. b. If you want me to send information about our therapy to someone else, you must sign a release-of-records form. c. Any information that you tell me and also share outside of therapy, willingly and publicly, will not be considered protected or confidential by a court.

The laws and rules on confidentiality are complicated. Please bear in mind that I am not able to give you legal advice. If you have special or unusual concerns, and so need special advice, I strongly suggest that you talk to a lawyer to protect your interests legally and to act in your best interests.

I have received, understand & had all my questions answered about: the Fiscal Policy & Information for Clients handouts, the Confidentiality & Consent (to Therapy and Telehealth) forms.

With enough knowledge, & without being forced, I hereby seek & consent to take part in therapy with Susanne Dillmann, Psy.D.

I understand that being an active participant, is essential for therapy to be effective. I agree to be engaged in the therapy process and expect us to work together on any difficulties that occur, and to work them out in my long-term best interest. I also understand that therapy is often emotionally difficult and that Dr. Dillmann will help me manage & cope.

I recognize that no promises have been made as to the end results of therapy. If I am not satisfied by our progress, I will inform Dr. Dillmann of this. I understand that I have the right to stop therapy at any time. If I choose to terminate, I will discuss this, as soon as possible, and recognize that I will still be responsible for any outstanding payment and for any consequences that come from this decision.

I have been informed that Dr. Dillmann is not available 24-hours, on Fridays or on the weekend. In addition, Dr. Dillmann, does not check the phone or emails while on vacation.

If I am in a life-threatening emergency I will: contact 9-1-1, the National Suicide Prevention Lifeline 1-800-273-TALK (1-800-273-8255), the Crisis Text Line by texting CONNECT to 741741, the San Diego County Access & Crisis Line at 1-888-724-7240 or go to an emergency room. I know I can leave an important but non-emergency phone message or email for Dr. Dillmann & she will establish contact with me during business hours, usually within 24 hours.

I understand that Dr. Dillmann encourages texts to be about non urgent issues, such as scheduling issues, and that all other types of communication ought to occur via phone or email. Dr. Dillmann will usually respond to texts within 24 hours and during business hours. Dr. Dillmann's texts are unencrypted.

Please know that Dr. Dillmann’s business hours are Monday - Thursday 10 am - 6pm, thus a message, email or text sent late in the day on Thursday may not be seen or responded to until the following Monday.

I know I must cancel at least 24 hours before my appointment. If I cancel late more than two times in a calendar year, Dr. Dillmann reserves the right to charge me a $40 late cancellation fee. If I am more than 20 minutes late and have not contacted Dr. Dillmann, she has the right to cancel the session and deem it a ‘late cancel’.

I have been informed that Dr. Dillmann maintains an electronic client file (through Simple Practice) in accordance with state and federal law as well as in accordance with the American Psychological Association’s record keeping guidelines & ethics code. I understand that Dr. Dillmann uses password protections on all of her technology devices.

I understand that if I am not in contact with Dr. Dillmann for six weeks, she may ‘close’ my file and that I am more than welcome to re-engage in therapy at any time in the future. I understand that emails sent to Dr. Dillmann are part of my legal record and will be included in my file that text and phone messages are noted in my file. I understand that if I want to receive encrypted emails, that I can ask for this.

I understand that Dr. Dillmann does not engage with clients, current or former, on social media. Dr. Dillmann does not look up clients on social media or via the internet. Dr. Dillmann does nto request client testimonials on consumer/business review sites, such as Yelp, Health Grades, etc… and has not/does not list herself on these sites. In addition, Dr. Dillmann does not respond to any reviews on these sites, regardless of the content of the post, due to confidentiality laws.

I realize that if I utilize a third-party payer, information will be given to this entity about my services and that I am responsible for all fees the third-party payer declines to cover. If payment for the services I receive is not made Dr. Dillmann has the right to stop my therapy.

Engaging in our therapy session through a phone or video call (telehealth) creates unique risks, while also having benefits. It is important to Dr. Dillmann, that you fully understand the risks and efforts to minimize them.

The main risks have to do with limits to your confidentiality, as well as limits to the privacy and security of your personal information, which is shared during the use of the telehealth session.

With regards to your confidentiality, all of the confidentiality laws apply and Dr. Dillmann is not recording the session or taking photos of you. Dr. Dillmann conducts the telehealth session from either her home office or office.

It is important that you also find a private, quiet space, free from distractions, in which to have the telehealth session, so that others do not overhear or see you. The platform used for video sessions, Simple Practice, complies with the HIPAA and HITECH laws. They test hack their own site and meet the standards for bank level security - all to say that Simple Practice follows the strongest privacy and security standards. In addition to following these laws and standards, Simple Practice does not record or archive the content of our video session.

By signing this form and participating in the video session, you are agreeing to use Simple Practice. At the beginning of the video session, Simple Practice requires you to enter a name into a form fill box, which lets Dr. Dillmann know that you are ready for the call, please feel free to enter in an initial or fake name, for another layer of security.

Since you and Dr. Dillmann have scheduled the session, she knows that you are waiting for the call. Due to this being a video session, you will need to use a smart phone, computer or tablet to engage in the session. The microphone and camera on your device will be utilized in the session Dr. Dillmann is accessing Simple Practice through a secure (password protected) and private Wi-Fi connection. Dr. Dillmann maintains up to date antivirus protection. You are encouraged to do the same, as an unsecured connection could make you/our call vulnerable to breaches in security and privacy.

If our video call is dropped or the quality of sound or sight becomes too compromised, then Dr. Dillmann will end the video session and contact you by phone, thus allowing your session to continue. You will be billed for your whole session even though this drop in the video occurred.

Lastly, due to this being a video session, our ability to assess each other’s non-verbal cues, body language and facial expressions may be limited – so feel free to clarify any confusions on that front. It ought to be noted that video sessions may not be the most effective form of therapy for certain individuals or presenting problems.

The process of filing a complaint for teletherapy is the same as filing a complaint for in-person therapy. Since Dr. Dillmann is a psychologist, the appropriate board is the CA Board of Psychology (BOP), which is under the Department of Consumer Affairs http://www.dca.ca.gov/.The contact information for the Board of Psychology is as follows: Board of Psychology: 2005 Evergreen St. #1400 Sacramento, CA 95815 1-866-503-3221 bopmail@dca.ca.gov www.psychboard.ca.gov.