Agreement
CSS Fee Schedule, Policies, Information
Medication Management* $150
Psychotherapy Interview/Assessment $195
Consultation w/Mark D. Donovan* $300
Individual/Family Therapy $175
Intensive Outpatient Program $220
Family Group/Parent Education* $50
Report/Psychiatric Report* (per 1/2 hr) $50/$100
Relationship Counseling* $175
Brief Phone Session* $50
Parental Intervention* $300
Unscheduled Refill Request* $35
Insurance/Medication Auth* $25
Disability/Workers Comp Report* $300
Urine Screen* (see Lab Svcs below) $40
Psychiatrist/MD/NP Evaluation* $300
Consultation Only* $195
Letter/Forms* $35
Crisis Session/Call (per 5 min)* $45
Bounced Check Fee* $25
No Show Fee (therapy) $75
No Show Fee (IOP,psych) $100
*These services will not be billed to your insurance by our office. This is not a comprehensive list of all possible charges.
Cancellation and No Show Policy
It is office policy to charge for missed appointments not canceled at least 24 hours prior to the scheduled appointment. This includes groups: unless prior arrangements are made, you will be expected at the next scheduled group meeting. In the event a courtesy reminder is not made, it does not excuse a missed appointment.
IOP Services and Substance Abuse Diagnosis
For our IOP services to be covered under your insurance, a substance abuse diagnosis must be indicated. If the clinician determines that a diagnosis is not present, then the services are not billable to your insurance and will be considered self-pay.
Fees and Payment
Fees will be collected at the time service is rendered. Checks returned for non-payment will result in a $35 bounced check charge. Statements are regularly e-mailed, but can be mailed upon request. Congruent Counseling Services, LLC will only file reimbursable services with the primary insurance. If your insurance has not made payment within 60 days, we will ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount. Medicaid clients will not be charged for services rendered by mail, telephone or otherwise not in person; for completion of forms or reports; or for broken or missed appointments. Medicaid clients consent to the use of telehealth (video conferencing) in cases where in-person sessions are unavailable.
Failure to Pay
The client agrees that failure to pay the expected service fee within ten business days of the service date may, at the option of Congruent Counseling Services, be construed as a discharge of services by the client. Client accounts sent to collections for non-payment will be charged the amount owed plus any and all associated collection fees. The client agrees that information pertinent to the collection of any amount due may be released to a third party collection agency or attorney. The client further agrees that in the event that legal action is taken to collect any money under this agreement, the client shall pay the amount due as attorney collection fee as well as any cost of any legal action; and consents to legal action being held in Howard County, Maryland, and waives any right to claim improper jurisdiction and/or venue.
Court Appearances, Legal Requests and Associated Costs
Congruent Counseling Services charges a minimum of $3,200 for any court appearance or legal request (such as administrative hearing, subpoena) whether requested or summonsed, regardless of requesting party. Clients will also be charged additional $400 per hour with for any travel time, consultation time, preparation time, and any time spent waiting. Costs incurred by the company for associated legal fees will be passed on to the client. In the case of minors, the signing parent is responsible for this fee unless otherwise pre-arranged with the non-signing parent. A deposit of $3,200 is due 10 days prior to any court appearance or legal request. If a court appearance or legal request is canceled or rescheduled, staff must be given ten business days’ notice; without this notice, CCS may still charge up to $3,200 for each day if unable to reschedule appointments and hourly for any preparation time, administration time, and reports completed.
Understanding of Separate Practices
The client recognizes and understands that although they share space, Congruent Counseling Services, LLC (CCS) and Integrative Counseling, LLC (IC) are separate practices, and as such require the opening of a separate client chart. The client understands that any insurance benefits utilized with CCS cannot be utilized with IC. IC does not contract with insurance payers. Clients may continue to receive services from either or both programs. Additionally, the client understands that each program may exchange information with the other and the client signature below serves as a release for the programs to exchange such information as needed to ensure appropriate treatment.
Laboratory Services
CCS may contract with private laboratories to perform drug screening. Information about any outside laboratory can be requested from the front office or your counselor.
Medication Changes or Refills between Appointments
We understand you may sometimes need a brief refill to get you through to your next appointment. Refills between appointments will be billed at $35. These refills will be for no longer than two weeks or until you are able to see your psychiatrist or prescribing clinician in person. You may choose to schedule a Telepsychiatry appointment if the next appointment is too far away.
Client Portal
We offer you the option to access a portal to your account through which you can communicate with your provider, pay your bill, and verify your schedule. Please ask the front office for a login if you were not provided with one. If at any time you want to opt out of the portal, please let us know.
Communication, Reminders, Statements – Risks to Privacy
We wish to communicate with you in the most efficient way possible. That may be by phone, email, or text message. Telephone, email, and text messaging communications carry an inherent risk to privacy. Please do not use email for an emergency or rapid response request, or for sensitive information. We may use your email, mobile phone text messaging, or home phone for appointment reminders, statement delivery, or general information. By signing below, you acknowledge recognition and acceptance of risk to privacy in the use of email and text message.
Telephone and Internet Session – Teletherapy or Telepsychiatry
Clients regularly seen in the office for sessions under insurance may schedule telehealth appointments; most insurances pay for telehealth sessions, and we encourage you check with your benefits company. In the case of a missed appointment, therapists may opt to conduct a 15-30 minute phone session during your already scheduled individual, family, or couples appointment time. This session will be charged at a rate of $50, which is less than the full missed appointment charge. The missed appointment phone option may only be used once in a 30-day period.
Provider Contact Outside of Sessions
It is our goal to provide you with the best treatment we can provide. If there is an emergency, please call emergency services or 911, or Grassroots at 410-531-6677. If you are calling to make or change your appointment or to address billing issues, please call the office at 410-740-8066. Your clinician will provide you with personal contact information to help address your needs. If you would like to talk with your provider, and cannot wait until the next appointment, please be respectful of their time. Calls, texts, or emails taking over five minutes will be charged as a crisis session at a rate of $45 per 5 minutes. Contacts about medication clarification more than a week after your appointment will be charged as a Crisis Session. Crisis Sessions are not billable to insurance and are the responsibility of the client or guardian.
Client Responsibilities, Rules, Emergency Contact Information, Family Involvement
As part of this Client Orientation Packet, you will receive a copy of the Client Responsibilities and Rules and contact information for your assigned counselor, contacts for Emergency Services, and our grievance policy. You are encouraged to include your family in therapy and you are given the times for IOP family group sessions if appropriate.
Advance Directive
If you have an Advance Directive, please provide a copy of the document if you wish to have it on record. If you do not have an advance directive and would like to make one, please notify the front desk staff; they will provide you with the “Maryland Advance Directive for Mental Health Treatment” from the State of Maryland DHMH.
Scope of Practice – Description of Services
The complete description of program services is available on the website: http://www.congruentcounseling.com.
Notice of Privacy Practices (HIPAA), Client Rights and Confidentiality of Records
Client Bill of Rights
Each Client has the right to:
- Have self and property be treated with consideration, respect, and full recognition of the client’s human dignity and individuality;
- Receive treatment, care, and services that are adequate, appropriate, and in compliance with relevant State, local, and federal laws and regulations;
- Not be physically or mentally abused by the program staff;
- Be free from discrimination;
- Be free from restraints;
- Privacy and confidentiality; and
- Refuse participation in any experimental research unless the research complies with 45 CFR Part 46. 45 CFR Part 46 is the Code of Federal Regulations Protection of Human Subjects.
- Refuse treatment at any time and request a referral for outside services.
Confidentiality of Records and Records Request
Federal Law and Regulations protect the confidentiality of patient records maintained by this program. Generally, the program may not disclose to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug user unless:
- Clients aged 14 and older receiving substance use services and all other clients aged 16 and older provides consent in writing;
- The disclosure is allowed by court order;
- The disclosure is made to medical personnel in an emergency or to qualified personnel for research, audit, or program evaluation.
Violation of Federal Law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with federal guidelines. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program, or about any threat to commit such a crime. Federal law and regulations do not protect any information about suspected child abuse or neglect from being reported under state law to appropriate state and local authorities.
All records requests must be made in writing to the Columbia office; a response will be made within 21 working days. Records copies are charged $30 to the client prior to preparation.
Acknowledgment and Consent Regarding Notice of Privacy Practices
The Notice of Privacy Practices (NPP) of Congruent Counseling Services (CCS) provides information about how CCS may use and disclose your protected health information (PHI). The NPP states that CCS reserves the right to change its terms. Should this happen, understand that CCS will make the changed notice available in its office. You have the right to revoke this consent, in writing, except where CCS has already made disclosures in reliance on your prior consent. Understand that you have the right to request restrictions on how your PHI may be used or disclosed for treatment, payment and health care operations. CCS is not required to agree to your restrictions, but if it does, it is bound by its agreement with you. By signing below, you consent to the use and disclosure of your PHI for treatment, payment and health care operations as described in the NPP. You specifically consent to CCS communicating with you using the contact information you provide, as further described in the NPP.
Client Grievance Procedures
Clients have the right to discuss treatment issues, and if necessary to review with the Program Director, disagreements about treatment, discharge, or change in status. No retaliation will be taken against clients who present a grievance. Clients will first be asked to discuss concerns with their counselor. The counselor will attempt to resolve the client’s concerns. If the client is unsatisfied, they can write their complaint to the Program Director using the contact information below. The Program Director will communicate with all parties involved to gain a full picture of what occurred. Based on this information, the Program Director will create a resolution which best meets the needs of all involved. The Program Director will then write a response to the client within ten business days.
Adolescent Program Director:
Meghan Hesterberg, BS, CAC
443-917-2590
11:00am – 6:00pm
If the client is dissatisfied with the response from the Program Director, they can contact the following agencies:
DHMH/OHCQ:
Behavioral Health
410-402-8198
8:00am – 5:00pm
ACHC (Accreditation Body):
919-785-1214
8:00am – 5:00pm EST
Local Addictions Authorities:
Roe Rodgers-Bonaccorsy
LAA, Howard County
410-313-7316
9:00am – 3:30pm
Sue Doyle
LAA, Carroll County
410-876-4800
9:00am – 3:30pm
Sandra O’Neill
LAA, Anne Arundel County
410-222-7164
9:00am – 3:30pm
Mary Viggiani
LAA, Baltimore County
410-887-3828
9:00am – 3:30pm
Discharge
Clients who choose to terminate services will be discharged immediately. Clients who have not attended sessions for 30 days or more and who do not have an appointment scheduled will be discharged at the discretion of the doctor or therapist with no prior notice. Discharged clients are no longer under the care of Congruent Counseling Services, Integrative Counseling, a therapist, or a doctor. Discharged clients may be re-admitted at the discretion of the practice upon request.
Client Expectations and Rules
- A client who makes a threat or becomes violent will be discharged.
- A client who brings a weapon will be discharged.
- A client who becomes verbally abusive will be discharged.
- All state, county and federal laws will be observed. Violators will be turned in to the appropriate authorities. (Confidentiality – 42 CFR, part II will be observed.)
- If a client misses three appointments, the client will be discharged.
- If a client chooses to not actively participate in treatment, he/she may be discharged.
- A client’s refusal to pay for a service is grounds for discharge.
- Each session will begin and end on time. If a client is more than 10 minutes late, he/she will be considered as a no-show.
- Clients may be asked to give random urine drug screens or alcohol breathalyzer screens on a weekly basis. If the client refuses, he/she may be discharged at the discretion of the program directors. Clients receiving two positive urine or breathalyzer screens may be discharged from the program at the discretion of the program directors. Clients will be monitored while giving urine.
- If a client appears to have used illicit drugs or alcohol, staff will ask to speak with the client in private, a urine screen may be required and the client may be asked to leave treatment for the day. Clients will not be treated when under the influence of any illicit drug or alcohol.
- It is unlawful to manufacture, distribute, dispense, possess, use, or be under the influence of a controlled substances (without a prescription) in the program. Clients caught doing so may be discharged from the program immediately and referred for other services.
- All clients are expected to maintain the confidentiality of other clients.
Emergency Contact Information
Emergency Services 911
Grassroots Crisis Intervention 410-531-6677
Advance Directive
If you have an Advance Directive, please provide a copy of the document if you wish to have it on record. If you do not have an advance directive and would like to make one, please notify the front desk staff; they will provide you with the “Maryland Advance Directive for Mental Health Treatment” from the State of Maryland DHMH.
Scope of Practice – Description of Services
The complete description of program services is available on the website: http://www.congruentcounseling.com.
Clinical Supervision Provisions
Services may be provided by an LG/LM, a State of Maryland Certified Counselor, or ADT under the supervision of the Clinical Director Mark D. Donovan, LCPC, LCADC who can be reached at 10630 Little Patuxent Pkwy, Ste 209, Columbia, MD 21044, 410-740-8066. Counselor names and certification details can be viewed at www.integrative-counseling.com, or by request from your counselor. Certification can be verified at https://mdbnc.dhmh.md.gov/pctVerification/default.aspx. The client agrees to release such information as is required for supervision to the Clinical Supervisor for a period of one year.
CCS Infectious Disease Education/Risk Reduction
Tuberculosis
Tuberculosis (TB) is an infectious disease that usually infects the lungs but can attack almost any part of the body. Tuberculosis is spread from person to person through the air. When a person with TB in their lungs or throat coughs, laughs, sneezes, sings, or even talks, the germs that cause TB may spread through the air. If another person breathes in these germs, there is a chance that they will become infected with tuberculosis.
It is not easy to become infected with tuberculosis. Usually a person has to be close to someone with TB disease for a long period of time. TB is usually spread between family members, close friends, and people who work or live together. TB is spread most easily in closed spaces over a long period of time.
If it is not treated, TB can be fatal. But TB can almost always be treated and cured if you take medicine as directed by your healthcare provider. Once you begin treatment, within weeks you will no longer be contagious. That means you can’t spread the disease to others. If you take your medicine just as your healthcare provider tells you, all the TB germs should be killed.
Risk Reduction: Travelers should avoid close contact or prolonged time with known TB patients in crowded, enclosed environments (for example, clinics, hospitals, prisons, or homeless shelters). If you think you have been exposed to someone with TB disease, contact your healthcare provider or local health department to see if you should be tested for TB. Be sure to tell the doctor or nurse when you spent time with someone who has TB disease.
American Lung Association, http://www.lung.org/lung-disease/tuberculosis/
CDC: http://www.cdc.gov/tb/topic/infectioncontrol/
Tobacco Smoking
Cigarette smoking has been identified as the most important source of preventable morbidity (disease and illness) and premature mortality (death) worldwide. Smoking-related diseases claim an estimated 443,000 American lives each year, including those affected indirectly, such as babies born prematurely due to prenatal maternal smoking and victims of “secondhand” exposure to tobacco’s carcinogens. Smoking cost the United States over $193 billion in 2004, including $97 billion in lost productivity and $96 billion in direct health care expenditures, or an average of $4,260 per adult smoker.
Risk Reduction: Quitting smoking is the single most important step a smoker can take to improve the length and quality of his or her life. Stopping smoking can be tough but smokers don’t have to quit alone. The American Lung Association has lots of options to help adult and teen smokers quit smoking for good.
American Lung Assocation, <http://www.lung.org/stop-smoking/how-to-quit/>
HIV/AIDS
HIV is the human immunodeficiency virus. It is the virus that can lead to acquired immune deficiency syndrome, or AIDS. HIV damages a person’s body by destroying specific blood cells, called CD4+ T cells, which are crucial to helping the body fight diseases. Within a few weeks of being infected with HIV, some people develop flu-like symptoms that last for a week or two, but others have no symptoms at all. People living with HIV may appear and feel healthy for several years and can still spread the virus. HIV is spread primarily by not using a condom when having sex with a person who has HIV, sharing needles, and being born to an infected mother. If you believe you may have been exposed you need to see a doctor and get tested. Early treatment can reduce the spread of HIV and allow you to start treatment early to reduce the impact of the disease on your body.
Risk Reduction: Use condoms consistently and correctly. Reduce the number of people you have sex with. Talk to your doctor about pre-exposure prophylaxis (PrEP). PrEP should be considered if you are HIV-negative and in an ongoing sexual relationship with an HIV-positive partner. Talk to your doctor right away (within 3 days) about post-exposure prophylaxis (PEP) if you have a possible exposure to HIV. Get tested and treated for other sexually transmitted diseases (STDs) and encourage your partners to do the same. If your partner is HIV-positive, encourage your partner to get and stay on treatment.
CDC: http://www.cdc.gov/hiv/topics/basic/index.htm
AIDS.Gov: www.aids.gov/hiv-aids-basics/prevention/reduce-your-risk/sexual-risk-factors/
STDs
Sexually transmitted diseases, or STDs, can be painful and embarrassing. Unfortunately, they are especially common when safe-sex precautions are not taken. Luckily, most STDs are easily treatable by your doctor. If you’re afraid you might have an STD, consider these seven warning signs: painful urination; painful intercourse; open sores or bumps near the mouth or genitals; unusual discharge from the genitals/unusual odor; itching or swelling in the genital area; changes in menstruation; high fever, fatigue, or nausea. These can all be symptoms of an STD. If you feel as if you might be coming down with something shortly after having unprotected sex, don’t assume that it’s just a common cold. If you believe you might have an STD, you should make an appointment with your doctor as soon as possible.
Risk Reduction: There are several ways to avoid or reduce your risk of sexually transmitted infections: Abstain from sex; Stay with 1 uninfected partner; Avoid vaginal and anal intercourse with new partners until you have both been tested for STDs; Get vaccinated. Vaccines are available to prevent human papillomavirus (HPV), hepatitis A and hepatitis B. Also, Use condoms and dental dams consistently and correctly; Don’t drink alcohol excessively or use drugs. Communication: Teach your child that becoming sexually active at a young age tends to increase a person’s number of overall partners and, as a result, his or her risk of STDs. Consider male circumcision.
Reference: http://www.cdc.gov/STD/
Mayo Clinic: www.mayoclinic.org/diseases-conditions/sexually-transmitted-diseases-stds/basics/prevention/con-20034128
Hepatitis
Hepatitis is an inflammation of the liver. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances (e.g., alcohol, certain drugs), and autoimmune diseases can also cause hepatitis. There are 5 main hepatitis viruses, referred to as types A, B, C, D and E. These 5 types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.
Risk Reduction: Good personal habits will help reduce the spread of hepatitis A and hepatitis E. If you’re in a place where you’re not sure things are clean, boil water. Cook all food well and peel all fruit. If you’re a healthcare worker or caregiver for someone who has a contagious form of hepatitis, take extra steps to stay clean. Wash your hands, utensils, bedding, and clothes with soap and hot water. To prevent the spread of hepatitis B, stay away from the blood or body of someone who has it. That means no kissing or sex. Don’t share razors, scissors, nail files, toothbrushes, or needles. If you plan to travel to countries where hepatitis is widespread, get protected. You can get vaccinations for hepatitis A and B. In the U.S., all children are advised to receive a series of hepatitis B vaccine before they start school. Kids who live in places with a lot of hepatitis A should get that vaccine. There isn’t a vaccine for hepatitis C.
WHO: www.who.int/features/qa/76/en/
Web MD: www.webmd.com/hepatitis/understanding-hepatitis-prevention
For Treatment or Testing
See your doctor, or we recommend Dr. Patel, Family Health Center, 10632 Little Patuxent Pkwy, Suite 111, Columbia, MD 21044. Phone: 410.997.9751.