Informed Consent

Upon scheduling your intake session, you will be sent an Informed Consent & Policies form that more thoroughly describes Vivant CPT’s policies. This document also provides important information about what to expect in therapy. You are encouraged to download this document for your records when you complete it. Please contact your therapist if you would like to request a copy of this document and it will be provided to you.

HIPAA Notice of Privacy Practices

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. This Notice of Privacy Practices applies to Vivant Counseling & Psychotherapy. Effective date: February 2022. 

Vivant Counseling & Psychotherapy, PLLC (Vivant CPT) is committed to protecting the privacy of your Protected Health Information (PHI) about you for services you receive at Vivant CPT. Your privacy rights are governed over provisions of both state and federal law. Regulations include, but are not limited to:

• Illinois State Law regarding treatment records, confidentiality of records, confidentiality limitations, and reporting requirements

• United States Federal Law

• Health Insurance Portability/Accountability Act of 1996 (HIPAA)

• Ethical code of the American Counseling Association (ACA)

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach or suspected breach occurs that may have compromised the privacy of your information.

• We must follow the duties and privacy practices described above and give you access to this notification.

• We will not share your information other than those described unless you give us written permission. If you give permission, you can withdraw this permission at any time.

• We are required to abide by the terms of this notice until we officially adopt a new notice. We will provide a copy of the new notice.

• We are required to give you a copy of this notice.

Your Rights as a Client

• To obtain a copy of your health and claims records (we may charge a reasonable fee for this service)

• To ask us to correct health and claims records if they are incorrect or incomplete. We will give you a response to this request within sixty days, and we may decline this request.

• To request confidential communications. You can ask us to contact you in a specific way or send mail to a different address. We will consider all reasonable requests and must agree if you tell us that you would be in danger if we do not.

• To ask us to limit what we use or share. You can ask us NOT to share certain health information for treatment, payment, or operations. You have the right and choice to tell us to share information with your family, close friends, or others involved in payment for your care. You may also tell us whether to share information in a disaster relief situation. We are not required to agree to this request, and may decline if it would negatively affect your care. We never share your information for marketing or sale purposes unless you give us permission.

• To obtain a list of those with whom we’ve shared information, including the reason for sharing information. This accounting of disclosures of information can be for up to six years prior to the date you ask. The accounting will include all disclosures except for those we have made about your treatment, payment, or healthcare operations, and certain other disclosures, such as those you requested that we make. You are able to receive one such accounting per year, after that, we may charge a reasonable cost-based fee.

• To request not to share information with your insurer if you pay for services out of pocket.

• To obtain a paper copy of this Notice of Privacy Practices.

• To choose someone to act for you if you have given someone medical power of attorney or if someone is your legal guardian. We will confirm the authority of this person before we take any action.

• To opt out of marketing or fundraising solicitations.

• To file a complaint if you feel your rights are violated. You can contact us or file a complaint with the US Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, SW, Washington DC 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/what-to-expect/index.html. We will not retaliate against you for filing a complaint.

How We Use Your Protected Health Information

The most common ways we use or share your health information is to treat you (e.g., sharing of information to covered entities that are not part of your direct treatment team), to operate our practice (e.g., to contact you, schedule appointments, etc.), and to bill for our services.  The less common ways we use or share you health information include: when we must report suspected abuse, neglect, or domestic violence, report adverse medication reactions, assist with public health and safety issues, prevent or reduce a serious threat to anyone’s health or safety, to prevent disease, to conduct research, to support government functions, to contribute to the public good, to respond to workers’ compensation claims, to support health oversight agencies’ activities as authorized by law, to comply with state or federal laws, to respond to law enforcement requests, to assist with product recalls, and to respond to lawsuits or legal actions.

How We Will NOT Use Your Protected Health Information

• We will not use your PHI for marketing purposes without your written permission.

• We will not share psychotherapy notes in most cases without express written authorization from you.

• We will not sell your health information.

We can change the terms of this notice and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website. You will also be notified via email if there are changes to this notice. If you have questions about our privacy policies or feel that your privacy rights have been violated, please contact our Chief Privacy Officer, Clara Donaldson, at 773-234-2767 or clara@vivantcpt.com.

Financial Policies

All payment is due in full at the time of service. Session fees are automatically charged to your payment method on file after each session. If your payment method on file does not go through, you will be notified and must provide alternate means of payment before your next scheduled session. Clients are not allowed to carry balances, and having an unpaid balance may affect your ability to schedule future appointments. If you are the parent/guardian of a minor receiving counseling services, you are responsible for all associated fees.

If you need to cancel or reschedule your appointment, you must do so at least 24 hours in advance of your scheduled appointment. If you miss your appointment or request to cancel/reschedule within 24 hours, you will be subject to a $100 fee. If you contact your therapist outside of business hours, your request will still be received as long as you provide 24 hours notice.

If you are using insurance to pay for sessions, you are responsible for knowing your coverage and for paying any fees not covered by insurance. Vivant Counseling & Psychotherapy will file claims to your insurance company. It may take a few weeks for claims to process and sometimes coverage may be different from the initial estimate we retrieve. Once your claims are processed, your therapist will inform you promptly of any unexpected costs. If your insurance company is out of network, it is your responsibility to request a receipt of services from your therapist.

Good Faith Estimate for Health Care Items and Services

The No Surprises Act (Under Section 2799B-6 of the Public Health Service Act) was enacted in 2020 with the goal of protecting patients from unexpected bills for healthcare services. Beginning January 1, 2022, mental health care providers are required by law to give self-pay clients a good faith estimate of costs for services when scheduling care or when the patient requests an estimate.

If you are paying out of pocket for your counseling services, we will provide you with a Good Faith Estimate upon scheduling your intake session. This Good Faith Estimate is valid for 12 months from the date it was created.

The Good Faith Estimate shows the costs of items and services that are reasonably expected for the above noted service. The estimate is based on information known at the time the estimate was created; actual services or charges may differ. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. Your therapist may recommend additional services that are not in the Good Faith Estimate. This Good Faith Estimate does not obligate you to obtain listed services. If you have health insurance, and the services you are seeking are covered by your health care plan, you may be able to get the items or services described in this notice from providers who are in-network with your health plan. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.