Mandatory Disclosure, Informed Consent, & Practice Policies
MANDATORY DISCLOSURE, INFORMED CONSENT, & PRACTICE POLICIES
1. INFORMATION
Samantha Tenner, PLLC
789 N Sherman St. Suite 650
Denver, CO 80203
2. CREDENTIALS
Degrees: Masters in Social Work (MSW), University of Denver, 2015
Status: Licensed Clinical Social Worker
Certified Sex Therapist
Professional Experience: From 2016 - 2018 I have received clinical experience, under supervision, at Denver Family Institute (DFI) providing services to counseling clients as an LCSW in the area of treatment of emotional problems, LGBTQ+ issues, anxiety, and relationship issues. I have been in private practice since then and received my CST in 2021 from AASECT.
REGULATION OF PSYCHOTHERAPISTS:
The practice of licensed or registered persons in the field of psychotherapy is regulated by the Mental Health Licensing Section of the Division of Registrations. The regulatory boards can be reached at 1560 Broadway, Suite 1350, Denver, Colorado 80202, (303) 894-7800. Levels of regulation of mental health professionals in Colorado include licensing (requires minimum education, experience, and examination qualifications), certification (requires minimum training, experience and for certain levels, examination qualifications, and registration (does not require minimum education, experience, or training.) All levels of regulation require passing a jurisprudence take-home examination. The regulatory requirements for mental health professionals provide that a Licensed Clinical Social Worker, a Licensed Marriage and Family therapist and a Licensed Professional Counselor must hold a Master’s degree in their profession and have two years of post-masters supervision. A Licensed Psychologist must hold a Doctorate degree in psychology and have one year of post-doctoral supervision. A Licensed Social Worker must hold a Master’s degree in social work. A Psychologist Candidate, a Marriage and Family Therapist Candidate and a Licensed Professional Counselor Candidate must hold the necessary licensing degree and be in the process of completing the required supervision for licensure. A Certified Addiction Technician must be a high school graduate, complete required training hours, pass the National Certified Addiction Counselor Exam, Level I or an equivalent exam, and complete 1,000 hours of supervised experience. A Certified Addiction Specialist must have a bachelor’s degree or higher in substance abuse/behavioral health, complete additional required training hours, pass the National Certified Addiction Counselor Exam, Level II or an equivalent exam and complete 2,000 hours of supervised experience. A Licensed Addiction Counselor must have a clinical master’s or doctorate degree, pass the Master Addiction Counselor Exam or an equivalent exam, and complete 3,000 of supervised experience. An Unlicensed Psychotherapist is listed in the State’s Database and is authorized by law to practice psychotherapy in Colorado, but is not licensed by the state and is not required to satisfy any standardized educational or testing requirements to obtain registration from the state.
CLIENT RIGHTS AND IMPORTANT INFORMATION:
a. You are entitled to receive information from me about my methods of therapy, the techniques I use, the duration of your therapy (if I can determine it), and my fee structure. Please ask if you would like to receive this information.
b. You can seek a second opinion from another therapist or terminate therapy at any time.
c. In a professional relationship (such as ours), sexual intimacy between a therapist and a client is never appropriate. If sexual intimacy occurs, it should be reported to the Department of Regulatory Agencies, Mental Health Section.
d. Generally speaking, information provided by and to a client in a professional relationship with a psychotherapist is legally confidential and the therapist cannot disclose the information without the client’s consent. There are several exceptions to confidentiality which include: (1) I am required to report any suspected incident of elder abuse, child abuse or neglect to law enforcement (2)I am required to report any threat of imminent physical harm to others by a client, including people identifiable by their association with a specific location or entity, to law enforcement and to the person(s) threatened; (3) I am required to initiate a mental health evaluation or make a report of a client who is imminently dangerous to self or to others, or who is gravely disabled as a result of a mental disorder; (4) I am required to report any suspected threat to national security to federal officials; and (5) I may be required by Court Order to disclose treatment information (6) I am required to report child pornography use (7) I may disclose confidential information if a client files suit against me or from any cause of action arising out of or connected with the care or treatment of a client or if a review of services is conducted of myself by a board or group authorized.
Please be advised that there is no time limit on the mandatory reporting of child abuse. This means that even adult clients who experienced childhood abuse (no matter how long ago) might disclose in therapy past abuse incidents that still fall under the mandatory reporting requirements. The law requires that if there is reasonable cause to know or suspect that the perpetrator has subjected any other child currently under eighteen years of age to abuse or neglect or to circumstances or conditions that would likely result in abuse or neglect and/or is in any “position of trust” with children today then past abuse disclosed by an adult client is required to be reported. If you have questions or concerns about these requirements, please discuss further with your therapist.
e. A client’s records may not be maintained after seven years pursuant to section 12-245-226 (1)(a)(II)(A).
f. Client Authorization or Consent: I may not use or disclose protected health information in any other way, aside from the mandatory reporting requirements, without a signed Authorization or Release of information. When you sign an authorization or Release of Information, it may later be revoked, provided that the revocation is in writing. The revocation will then apply.
f. Minor Children: If you are consenting to the treatment of a minor child, you will be required to provide a copy of the most recent Court Order Custody Agreement and/or Parenting Plan, if applicable, that gives you the authority to consent to the treatment of the child. By signing this form, you agree to keep me informed of any supplemental court orders or other proceedings that impact your parental rights, custody arrangements, or decision-making authority. Failure to produce the Court Order will prohibit me from seeing the minor child. If there is joint medical decision-making authority for your child, I will require both parents to consent to treatment and will not proceed until such consent is obtained.
It is beyond the scope of my practice to provide custody recommendations, and any such request will be denied. The Court can appoint professionals who have the expertise to make such recommendations. By signing below, you agree not to subpoena my records or ask me to testify in court or to provide letters or documentation expressing my opinion about custody or visitation. Despite this, a Court may still require me to testify or to provide treatment information to an evaluator. I will comply with these requests as legally required and you will be required to compensate me for time spent providing these services as indicated in the “Professional Fees” section above.
In the course of treatment with your child, I may involve other family members in your child’s treatment. However, please remember that my client is your child, not the other family members of the child. Any meetings with you or other family members will be documented in your child’s record. These notes will be available to anyone who has legal access to your child’s treatment record.
When treating a minor client where there is a custody arrangement between the parents or legal guardians (such as a divorce or separation), it is my policy to communicate with both parents/guardians via email (i.e. all communication will “cc” both parties). This policy is necessary to maintain transparency and professionalism, and to ensure the well-being of the therapeutic relationship with the minor client.
Therapy is most effective when there is a trusting relationship between the therapist and client. Privacy is important in establishing trust, and as a result, it is often important for child or adolescent clients to have a level of privacy around the therapy. It is my policy to provide parents with general information about their child’s treatment, but not to share specific information disclosed during therapy. This includes behaviors that you may not approve of but which do not place your child at imminent risk or danger. If I ever feel that your child is in danger, I will communicate this information to you. By way of example, if your child tells me that s/he has tried alcohol a few times at parties, I will not generally share this with you. If your child shares that s/he has been drinking and driving or riding with a drunk driver, I would share this information with you. If you have questions about the types of information I will share, you can feel free to ask me hypothetical questions about situations that I would or would not disclose to you.
Although you may have the legal right to access any written record I keep, by signing this agreement you are agreeing that your child or adolescent should have privacy around their therapy and you agree not to request access to your child’s full record.
Under Colorado law, C.R.S.§14-10-123.8, parents have the right to access mental health treatment information concerning their minor children, unless the court has restricted access to such information. If you request treatment information from me, I may provide you full access to the record in compliance with HIPPA standards. I will offer you a treat summary if that is acceptable.
g. I have a “no secrets” policy when working with couples and families. I will not keep information confidential that is told to me via e-mail, phone, or in session from other members of the family or couple involved in the therapy process.
NOTICE FOR MEDICAID MEMBERS: I am not a Medicaid provider and am unable to provide services to Medicaid members, however, I can refer you to a Medicaid provider.
h. Fees: Sessions are $165 per 50 minutes. I do not accept insurance. You are responsible for the entire fee. I can; however, provide you with a superbill.
If you become involved in legal proceedings, I charge $200 per hour for services related to your legal matter. You will be responsible for paying for any professional time I spend on your legal matter, even if the request comes from another party. Professional time spent on your legal matter includes, but is not limited to: attorney fees that I may incur in preparing for or complying with the requested legal services; testimony related matters such as case research, report writing, travel, depositions, actual testimony, cross examination, and courtroom waiting time.
You will be expected to pay for each session at the time it is held unless we have agreed otherwise in advance. If your account has not been paid for more than thirty (30) days and payment arrangements have not been agreed upon, your account will be considered past due and I have the option of using legal means to secure the payment. This may involve using a collection agency or filing a claim in small claims court. In collection situations, I will make all efforts to release the minimum information necessary to proceed with collections or a claim, which will include the client name, dates, times, and the nature of services, and the amount due. Before I engage a collection agency, I will provide you with written notice of my intent to do so, sent to your last address I have on record, and give you an opportunity to make payment arrangements.
If your card on file is declined or has insufficient funds, I will notify you and it is your responsibility to make sure the appropriate amount of funds is transferred to the card on file.
i. Appointments and Cancellations: Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire fee if cancellation is less than 24 hours. This is necessary because a time commitment is made to you and is held exclusively for you. If you are late for a session, you may lose some of that session time.
The standard meeting time for psychotherapy is 50 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the 50- minute session needs to be discussed with the therapist in order for time to be scheduled in advance.
j. Telehealth: I offer telehealth communication for clients physically present within the State of Colorado seeking therapeutic treatment within the State of Colorado. A separate informed consent for telehealth will be administered to those seeking these services.
k. Electronic Communication: I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so; however, I cannot guarantee the confidentiality of any information communicated by email or text. There is potential for third parties to view electronic communications if they are not secured. I will take reasonable steps to ensure the privacy and security of your information, and it is important for you to review your own security measures and ensure that they are adequate to protect information on your end. If you need to contact me between sessions, please leave a message on my voicemail. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies. Please let me know ahead of time if there is a form of communication that you prefer not to use or mark it within the simple practice platform in which you will sign documents.
l. Social Media: Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.
m. Termination: Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment after appropriate discussion with you and a termination process if I determine that the psychotherapy is not being effectively used or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons and purpose of terminating. If therapy is terminated for any reason or you request another therapist, I will provide you with a list of qualified psychotherapists to treat you. You may also choose someone on your own or from another referral source.
Should you fail to schedule an appointment for three consecutive weeks, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.
n. Identification of Professional Designee: In the event that I am disabled, die, or become incapacitated, the following provider will act as my Professional Designee and will have access to my client files: Loraine Fishman, PsyD. The Professional Designee will contact you to notify you of the event and will assist in continuing your care and treatment with the least amount of disruption possible by providing you with referrals and transferring your client record, if requested, to your new provider. If you are not comfortable with the above listed Professional Designee for any reason, please let me know and we will discuss alternatives.
LIMIT OF SERVICES AVAILABLE: Samantha Tenner does not provide emergency and after-hours services. If you find yourself in a life-threatening situation and are unable to contact Samantha, you agree to take the necessary steps to keep yourself safe, up to and including calling the CO crisis hotline number at 844-493-8255, call 911, or go to the emergency room (at your cost) if necessary.
I do not provide medications, psychiatric services, or psychological testing.
If you are involved in a divorce or custody litigation, you need to understand that my role as a therapist is not to make recommendations for the court concerning custody or parenting issues or to testify in court concerning opinions on issues involved in the litigation. By signing this disclosure statement, you agree not to call me as a witness in any such litigation. Experience has shown that testimony by therapists in domestic dispute cases causes damage to the clinical relationship between a therapist and client. Only court-appointed experts, investigators, or evaluators can make recommendations to the court on disputed issues concerning parental responsibilities and parenting plans.
PLEASE NOTE: Child abuse refers to any child abuse you discuss in therapy or that is observed. This includes illegal sexual contact between two minors, or abuse of children outside your family. I am mandated to report suspected child abuse.
Privacy Practices
NOTICE OF PRIVACY PRACTICES
This notice describes how medical information (including mental health) about you may be used and disclosed and how you can get access to this information.
Please review it carefully.
During the process of providing services to you, I will obtain, record, and use mental health and medical information about you that is protected health information. Ordinarily that information is confidential and will not be used or disclosed, except as described below.
I. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (PHI)
A. General Uses and Disclosures Not Requiring the Client’s Consent. I may use and disclose PHI about you without your authorization in the following circumstances:
1. Treatment. Treatment refers to the provision, coordination, or management of health care and related services by one or more health care providers. For example, I may use your information to plan your course of treatment and to consult with another health care provider to ensure the most appropriate methods are being used to treat you.
2. Payment. Payment refers to the activities undertaken by a health care provider to obtain or provide reimbursement for the provision of care. I may use and give your information to others to bill and collect payment for the treatment and services provided to you. For example, I may share portions of your information with billing services and billing personnel, collection services, insurance companies, health plans, and third party payers that provide you coverage. The information provided to insurers and other third party payers may include information that identifies you, as well as your diagnoses, type of service, date of service, provider name/identifier, and other information about your condition and treatment.
3. Health Care Operations. Health Care Operations refers to activities that are regular functions of the management and administrative activities. For example, I may use your health information in monitoring of service quality, training and education, medical reviews, legal services, auditing functions, compliance programs, business management and general administrative activities, and planning for future operations.
4. Contacting the Client. I may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that maybe of interest to you.
5. Required by Law. I will disclose protected health information when required by law. This includes, but is not limited to the following situations: i. Reporting child abuse/elderly abuse or neglect; ii. When the disclosure is for judicial and administrative proceedings, for example in response to an order of a court or administrative tribunal; iii. When there is a legal duty to warn or take action regarding imminent danger of others; iv. When the client is a danger to self or others or gravely disabled;
v. When required to report certain communicable diseases and certain injuries; vi. When a Coroner is investigating the client’s death; and vii. To government regulatory and oversight agencies which are authorized by law to oversee my operations.
6. Crimes on the premises or observed by Samantha Tenner, PLLC. Crimes observed by me, which are directed toward me or occur on the premises of our office, will be reported to law enforcement.
7. Business Associates. Some of the functions of the health care providers are provided by contracts with business associates. For example, some clinical, quality assurance, legal, auditing, and practice management services may be provided by contracting with outside entities to perform these services.
i. In those situations, protected health information will be provided to those contractors as is needed to perform their contracted tasks. In those situations, the business associates are required to enter into an agreement maintaining the privacy of the protected health information released to them.
8. Research. I may use or disclose protected health information for research purposes if the relevant limitations of the Federal HIPAA Privacy Regulations are followed. 45CFR §164.512(i).
9. Involuntary Clients. Information regarding clients who are being treated involuntary will be shared with other treatment providers, legal entities, and others, as necessary to provide the care and management coordination needed.
10. Family Members. Except for certain minors, incompetent clients, or involuntary clients, protected health information cannot be provided to family members without the client’s consent. In situations where family members are present during a discussion with the client, and it can be reasonably inferred from the circumstances that the client does not object, information may be disclosed in the course of that discussion. However, if the client objects, protected health information will not be disclosed.
11. Emergencies. In life threatening emergencies, I will disclose information necessary to avoid serious harm or death.
B. Client Authorization or Consent. I may not use or disclose protected health information in any other way without a signed Authorization or Release of Information. When you sign an Authorization or Release of Information, it may later be revoked, provided that revocation is in writing. The revocation will apply except to the extent that I have already relied on it.
C. Psychotherapy Notes. I may maintain psychotherapy notes separately from the remainder of my records. Use or disclosure of these notes will only occur under these circumstances: (a) you specifically authorize their use or disclosure in a separate written authorization; (b) I use them for your treatment; (c) I may use them for my own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family or individual counseling; (d) if you bring a legal action and I have to defend myself; and (e) certain limited circumstances defined by law.
II. YOUR RIGHTS AS A CLIENT
A. Additional Restrictions. You have the right to request restrictions on certain uses and disclosures of protected health information as provided by § 164.522(a). I am not required to agree to your request, and there are certain limits to any restriction, which will be provided to you at the time of your request. To exercise your right, discuss it with me.
B. Alternative Means of Receiving Confidential Communications. You have the right to request that you receive communications of protected health information by alternative means or alternative locations as provided by § 164.522(b). For example, if you do not want to receive bills or other materials at your home, you may request that this information be sent to another address. To exercise this right, discuss it with me.
C. Access to Protected Health Information. You have a right to inspect and obtain a copy of the protected health information contained in clinical, billing and other records used to make decisions about you as provided by § 164.524. Your request must be in writing. We may charge you related fees. There are some limitations to this right, which will be provided with you at the time of your request, if any such limitation applies. To exercise this right, discuss with me.
D. Amendment to Your Record. You have the right to request amendment of your protected health information as provided by § 164.526. Your request must be in writing and it must explain why the information should be amended. We are not required to amend the record if it is determined that the record is accurate and complete. There are other exceptions, which will be provided to you at the time of your request, relevant, along with the appeal process available to you. To exercise this right, discuss this with me.
E. Accounting of Disclosures. You have the right to receive an accounting of disclosures I have made regarding your protected health information as provided by §164.528. However, that accounting does not include disclosures that were made for the purpose of treatment, payment, or health care operations. In addition, the accounting does not include disclosures made to you, disclosures authorized by you, or disclosures made prior to October 1st, 2021. There are other exceptions that will be provided to you, should you request an accounting. To exercise this right, discuss with me.
F. Copy of the Notice. You have a right to request a paper copy of this Notice at any time.
III. ADDITIONAL INFORMATION
A. Privacy Law. We are required by law to maintain the privacy of your protected health information. We are also required to provide clients with notice of my legal duties and privacy practices with respect to protected health information. That is the purpose of this notice.
B. Terms of the Notice. We are required to abide by the terms of this Notice currently in effect, or any amended Notice that may follow.
C. Changes to the Notice. We reserve the right to change our privacy practices and the terms of this Notice at any time, and to make the new Notice provisions effective for all protected health information that we maintain. When changes are made, the revised Notice will be sent to you. Copies of this Notice will be available upon request.
D. Complaints Regarding Privacy Rights. If you are concerned that I have violated your privacy rights, you may file a complaint with me directly, in writing, using the contact information provided at the end of this Notice. You also have the right to complain to the United States Secretary of Health and Human Services, 200 Independence Avenue, SW, Room 515F, HHH Bldg, Washington, DC 20201, (877) 696-6775. It is our policy that there will be no retaliation for your filing such a complaint.
E. Effective Date. This notice was first published June 1st, 2016 and last updated November 1st, 2021.
**F. *Additional Information. ***If you want more information about our privacy practices or have any questions or concerns, please contact our HIPAA officer directly.
G. Contact: Samantha Tenner, LCSW
720**-**504-7579
Samantha@samanthatennertherapy.com
Standard Notice Regarding the “No Surprises Act”
Dear Current And Potential Future Clients,
Congress has enacted a “No Surprises Act” which is set to go into effect 1/1/2022. The act is described as “new federal protections against surprise medical bills that take effect in 2022. Surprise medical bills arise when insured consumers inadvertently receive care from out-of-network hospitals, doctors, or other providers they did not choose” (please see https://www.kff.org/health-reform/issue-brief/no-surprises-act-implementation-what-to-expect-in-2022/).
It is highly unlikely this could affect our work together. There will be no situation in which you would “inadvertently” receive care from me or with no choice.
If we currently work together, you are already aware of my charges and your costs. If you are considering working with me, available information suggests I might need to provide you with a diagnosis before we even meet, which of course would be both unethical and impossible without a meaningful evaluation of your circumstances. At this time, multiple professional organizations are scrambling to understand the details of this law, to whom it applies and how to apply it. Guidance so far is uncertain and in many cases conflicting.
Rest assured that I will be as transparent with you about the costs of the services we agree on together.
In the meantime, I will comply with the law by providing the required documentation which you will see below and you will also receive a standard notice and consent document if we work together. You may also certainly ask me about any costs about which you may be unsure, and you will be provided clear information.
Please feel free to contact me if you have any related questions.
Samantha Tenner Therapy
789 Sherman St. Suite #650 Denver CO 80203
720-504-7579, samantha@samanthatennertherapy.com, www.samanthatennertherapy.com
YOUR RIGHTS AND PROTECTIONS AGAINST SURPRISE
MEDICAL BILLS
(OMB Control Number: 0938-1401)
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that haven’t signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care - like when you have an emergency or when you schedule a visit at an in-network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
Emergency services
If you have an emergency medical condition and get emergency services from an out-of-network provider or facility, the most the provider or facility may bill you is your plan’s in-network cost-sharing amount (such as copayments and coinsurance). You can’t be balance billed for these emergency services. This includes services you may get after you’re in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
Colorado law prohibits balance billing in situations where an insured obtains treatment from a participating provider. C.R.S. § 10-16-705(3).
Certain services at an in-network hospital or ambulatory surgical center
When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be out-of-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers can’t balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers can’t balance bill you unless you give written consent and give up your protections.
You’re never required to give up your protection from balance billing. You also aren’t required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing isn’t allowed, you also have the following protections:
· You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-of-network providers and facilities directly.
· Your health plan generally must:
o Cover emergency services without requiring you to get approval for services in advance (prior authorization).
o Cover emergency services by out-of-network providers.
o Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
o Count any amount you pay for emergency services or out-of-network services toward your deductible and out-of-pocket limit.
If you believe you’ve been wrongly billed, you may contact: Colorado Department of Regulatory Agencies, Division of Professions and Occupations, 1560 Broadway, Suite 1350, Denver, CO 80202, 303-894-7800.
Visit https://www.cms.gov/files/document/model-disclosure-notice-patient-protections-against-surprise-billing-providers-facilities-health.pdf for more information about your rights under Federal law.