Bill Martin, LCSW 

Psychotherapy, Consultation & Training 773-936-3607 

1300 West Belmont Ave. # 309

Chicago, Illinois  60657

All information provided through this form is encrypted to protect your privacy and confidentiality.

Please read my Service Agreement, Confidentiality, & HIPPA Privacy Agreement

Please complete these forms and type your name as your signature. If for couples therapy, make sure both complete these forms.

Type your paragraph here.



I am providing you with this detailed information related to the HIPAA law. I, Bill Martin, am the manager for HIPPA and any questions or concerns may be directed to me at any time.

 

CONFIDENTIALITY: All information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without your written permission except where disclosure is required by law.

 

WHEN DISCLOSURE IS REQUIRED OR MAY BE REQUIRED BY LAW: Some of the circumstances where disclosure is required or may be required by law are: where there is a reasonable suspicion of child, dependent, or elder abuse or neglect; where a client presents a danger to self, to others, to property, or is gravely disabled; or when a client's family members communicate to I that the client presents a danger to others. Disclosure may also be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain the psychotherapy records and/or testimony by me or any other therapist you engage.  In couple and family therapy, or when different family members are seen individually, even over a period of time, confidentiality and privilege do not apply between the couple or among family members, unless otherwise agreed upon. I will use my clinical judgment when revealing such information. I will not release records to any outside party unless I am authorized to do so by all adult parties who were part of the family therapy, couple therapy or other treatment that involved more than one adult client.

 

EMERGENCY: If there is an emergency during therapy, or in the future after termination, where I becomes concerned about your personal safety, the possibility of you injuring someone else, or about you receiving proper psychiatric care, I will do whatever I can within the limits of the law, to prevent you from injuring yourself or others and to ensure that you receive the proper medical care. For my purpose, I may also contact the person whose name you have provided on the biographical sheet.

 

HEALTH INSURANCE & CONFIDENTIALITY OF RECORDS: Disclosure of confidential information may be required by your health insurance carrier or HMO/PPO/MCO/EAP in order to process the claims. If you so instruct me, only the minimum necessary information will be communicated to the carrier. I have no control over, or knowledge of, what insurance companies do with the information I may submit or who has access to that information. You must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk to confidentiality, privacy or to future capacity to obtain health or life insurance or even a job. The risk stems from the fact that mental health information is likely to be entered into big insurance companies' computers and is likely to be reported to the National Medical Data Bank. Accessibility to companies' computers or to the National Medical Data Bank database is always in question as computers are inherently vulnerable to hacking and unauthorized access.  Medical data has also been reported to have been legally accessed by law enforcement and other agencies, which also puts you in a vulnerable position.

 

LITIGATION LIMITATION: Due to the nature of the therapeutic process and the fact that it often involves making a full disclosure with regard to many matters which may be of a confidential nature, it is agreed that, should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you nor your attorney(s), nor anyone else acting on your behalf will call on me to testify in court or at any other proceeding, nor will a disclosure of the psychotherapy records be requested unless otherwise agreed upon.

 

CONSULTATION: I consult regularly with a consultant and other professionals regarding my clients; however, each client's identity remains completely anonymous and confidentiality is fully maintained.

 

E–MAILS, CELL PHONES, TEXTS, COMPUTERS, AND FAXES:

 

Summary statement: No electronic communication (email, text, voice-mail, etc) is secure. I will do my best to protect your privacy, but I can’t guarantee complete privacy.

 

 It is very important to be aware that computers and email communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. Faxes can easily be sent erroneously to the wrong address. Emails, in particular, are vulnerable to unauthorized access due to the fact that Internet servers have unlimited and direct access to all emails that go through them. It is important that you be aware that emails, faxes, and important texts are part of the medical records.

 

I have a secure email system operated by Email Pros.  I am able to send encrypted emails if you explicitly request. If you do, you will need to learn the process of getting the password to open the email itself. It is a few extra steps, but ensures your privacy.

 

If you decide to send me email, please use this address: bill@billmartinchicago.com.

 

I use a cell phone, can receive and text messages, and email, but can’t guarantee their privacy.

 

All my computers are equipped with a firewall, a virus protection, and a password. I back up all confidential information from my computers on a regular basis into an encrypted back up system.

 

Please notify me if you decide to avoid or limit in any way the use of any or all communication devices, such as email, cell phone, texts, or faxes.

 

If you communicate confidential or private information via email or texts I will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and will honor your desire to communicate to him on such matters via email.

 

Please do not use email, texts, phone messages, or faxes for emergencies. Always call 911.

 

If I believe your safety is at risk, related to substance use, self-harm, or otherwise, I will call 911 immediately and ask them to respond to your residence to do a safety check.

 

RECORDS AND YOUR RIGHT TO REVIEW THEM: Both the law and the standards of my profession require that I keep treatment records for at least 7 years. Unless otherwise agreed to be necessary, I will retain clinical records only as long as is mandated by Illinois law. If you have concerns regarding the treatment records, please discuss them with me. As a client, you have the right to review or receive a summary of your records at any time, except in limited legal or emergency circumstances or when I assess that releasing such information might be harmful in any way. In such a case, I will provide the records to an appropriate and legitimate mental health professional of your choice. Considering all of the above exclusions, if it is still appropriate, and upon your request, I will release information to any agency/person you specify unless I assess that releasing such information might be harmful in any way.  When more than one client is involved in treatment, such as in cases of couple and family therapy, I will release records only with signed authorizations from all the adults (or all those who legally can authorize such a release) involved in the treatment. I keep all records either in a digital format and saved in a secure manner or in a paper file.

 

TELEPHONE & EMERGENCY PROCEDURES: If you need to contact me between sessions, please call or leave a message at 773-936-3607.

 

This is my business cell phone and will answer your call if I am able. If not, I return your call as soon as possible. I check my messages frequently and am usually able to return messages or emails within 24 hours or sooner. However, I may not respond for up to 48 hours.

 

If you do not hear from me, I recommend you call back or email again as sometimes cell phone messages are garbled or are not received. Emails can get lost as well, so please do not assume I have received your message after one attempt.

 

When I am out of town, I usually have a colleague on call for any emergencies which might arise.

 

 If an emergency situation arises, indicate it clearly in your message and if you need to talk to someone right away call the Police: 911.

 

Please do not use email or faxes for emergencies. I do not always check my email daily.

 

PAYMENTS & INSURANCE REIMBURSEMENT: I accept Blue Cross Blue Shield PPO and Medicare insurance programs.

 

Individual psychotherapy is usually reimbursed by insurance companies, as long is it is medically necessary, based on my initial assessment. Couples or marital therapy is not always covered and clients are expected to confirm with their own insurance company. Whether or not an insurance company confirms they will cover the charges for couples/marital therapy, I expect clients to cover the expenses at the time of the session.

 

Other clients without insurance are expected to pay the self-pay at the time of the session.

Telephone conversations, site visits, writing and reading of reports, consultation with other professionals, release of information, reading records, longer sessions, travel time, etc. will be charged at the same rate, unless indicated and agreed upon otherwise.

 

Please notify me if any problems arise during the course of therapy regarding your ability to make timely payments. Clients who carry insurance should remember that professional services are rendered and charged to the clients and not to the insurance companies. Unless agreed upon differently, I will provide you with a copy of your receipt or financial records whenever you request, which you can then submit to your insurance company for reimbursement, if you so choose. If you have Blue Cross Blue Shield or Medicare insurance, I will be submitting the claim electronically and you will only be responsible to pay the deductible and copay at the time of the session. As was indicated in the section, Health Insurance & Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries a certain amount of risk.

 

Not all issues/conditions/problems, which are dealt with in psychotherapy, are reimbursed by insurance companies. It is your responsibility to verify the specifics of your coverage. If your account is overdue (unpaid) and there is no written agreement on a payment plan, I begin to charge 15% monthly on any unpaid balances. I also reserve my right to use legal or other means (courts, collection agencies, etc.) to obtain payment.

 

MEDIATION & ARBITRATION: All disputes arising out of, or in relation to my agreement to provide psychotherapy services shall first be referred to mediation, before, and as a pre-condition of, the initiation of arbitration. The mediator shall be a neutral third party chosen by agreement of myself and the client(s). The cost of such mediation, if any, shall be split equally, unless otherwise agreed upon. In the event that mediation is unsuccessful, any unresolved controversy related to my agreement should be submitted to and settled by binding arbitration in (your county, state) in accordance with the rules of the American Arbitration Association which is in effect at the time the demand for arbitration is filed.  The prevailing party in arbitration or collection proceedings shall be entitled to recover a reasonable sum for attorney's fees. In the case of arbitration, the arbitrator will determine that sum.

 

THE PROCESS OF THERAPY/EVALUATION AND SCOPE OF PRACTICE: Participation in therapy can result in a number of benefits to you, including improving interpersonal relationships and resolution of the specific concerns that led you to seek therapy. Working toward these benefits, however, requires effort on your part.



Psychotherapy requires your very active involvement, honesty, and openness in order to change your thoughts, feelings, and/or behavior. I will ask for your feedback and views on your therapy, its progress, and other aspects of the therapy and will expect you to respond openly and honestly. Sometimes more than one approach can be helpful in dealing with a certain situation. During evaluation or therapy, remembering or talking about unpleasant events, feelings, or thoughts can result in you experiencing considerable discomfort or strong feelings of anger, sadness, worry, fear, etc., or experiencing anxiety, depression, insomnia, etc.


I may challenge some of your assumptions or perceptions or propose different ways of looking at, thinking about, or handling situations, which can cause you to feel upset, angry, depressed, challenged, or disappointed. Attempting to resolve issues that brought you to therapy in the first place, such as personal or interpersonal relationships, may result in changes that were not originally intended.


Psychotherapy may result in decisions about changing behaviors, employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family member is viewed quite negatively by another family member. Change will sometimes be easy and swift, but more often it will be slow and even frustrating. There is no guarantee that psychotherapy will yield positive or intended results.


During the course of therapy, I am likely to draw on various psychological approaches according, in part, to the problem that is being treated and my assessment of what will best benefit you. These approaches include, but are not limited to, behavioral, cognitive-behavioral, cognitive, psychodynamic, Eye Movement Desensitization and Reprocessing, imagery, family system/family, developmental (adult, child, family), humanistic or psycho-educational.


I do not provide custody evaluations or recommendations, or medication or prescription recommendation nor legal or financial advices, as these activities do not fall within my scope of practice.

 

TREATMENT PLANS: Within a reasonable period of time after the initiation of treatment, I will discuss with you my working understanding of the problem, treatment plan, therapeutic objectives, and my view of the possible outcomes of treatment. If you have any unanswered questions about any of the procedures used in the course of your therapy, their possible risks, my expertise in employing them, or about the treatment plan, please ask and you will be answered fully. You also have the right to ask about other treatments for your condition and their risks and benefits.

 

TERMINATION: As set forth above, after the first couple of meetings, I will assess if I can be of benefit to you. I do not accept clients who, in my opinion, I cannot help. In such a case, I will give you a number of referrals that you can contact. If at any point during psychotherapy, I assess that I am not effective in helping you reach the therapeutic goals or that you are non-compliant, I have an obligation to discuss this with you and, if appropriate, terminate treatment. In such a case, I would give you a number of referrals that may be of help to you. If you request it and authorize it in writing, I will talk to the psychotherapist of your choice in order to help with the transition. If, at any time, you want another professional's opinion or wish to consult with another therapist, I will assist you with referrals, and, if I have your written consent, I will provide her or him with the essential information needed. You have the right to terminate therapy at any time. If you choose to do so, and if appropriate, I will offer to provide you with names of other qualified professionals.

 

DUAL RELATIONSHIPS:  My policy is not engage in dual or multiple relationships with my psychotherapy clients. My role as a therapist gives me more power in the relationship and I am always mindful of that. I ask you do not invite me to join any social network site or attend any events outside of my psychotherapy office, such as a celebration or even a wedding. I do not accept gifts and ask you to understand it is not necessary for you to give me anything, even something you think has no value.

 

If there is some other program or therapy I suggest, I will always offer you information to help you make a decision. I will never make any suggestions for you to engage in anything for which I may benefit financially or professionally. It should not be necessary to state this, but therapy never involves sexual or any personal relationships. A therapist can be friendly, but is never a friend, even after therapy is formally terminated.

 

Also when working with couples, I only do so together and avoid any individual sessions with either member of the relationship, unless well planned. It is important to realize that in some communities, particularly small towns, military bases, university campus, etc., multiple relationships are either unavoidable or expected. If I happen to see you in the community, I ask you to not acknowledge me or introduce me to anyone you are with. I will never acknowledge working with anyone without my written permission.

 

SOCIAL NETWORKING AND INTERNET SEARCHES: I do not accept friend requests from current or former clients on social networking sites, such as Facebook. I believe that adding clients as friends on these sites and/or communicating via such sites is likely to compromise their privacy and confidentiality. For the same reason, I request that clients not communicate with me via any interactive or social networking web sites.

 

CANCELLATION: Since the scheduling of an appointment involves the reservation of time specifically for you, a minimum of 48 hours (2 days) notice is required for re-scheduling or canceling an appointment. Unless we reach a different agreement, the full fee will be charged for sessions missed without such notification. Insurance companies do not reimburse for missed sessions.


 

Problem List:

Please check each item relevant to your concerns.

Fee Schedule


$40,000 and less                             $90
$40-$60,000                                   $130
$60-80,000                                     $150
$80,000  & over                               $175


Determination of fees also include income, savings and assets such as real estate and stock funds.

Do you know your insurance benefits for counseling/mental health?


The following information and list of questions will help you know what to ask when you call your insurance company.



The most important question is to ask is:

“Is William F. Martin, LCSW an approved IN-network provider? If not, is he covered as an out of network provider?


His NPI # is 1710072244.”



After making sure I am a PPO provider in your network, ask and record the answers to the following questions:



Do I need pre-authorization? If yes, how is that done?
What is my annual deductible?
How much of my deductible has been met?
How much of my deductible remains to be paid?
When does my deductible period begin and end?
What is my co-payment to the provider at each session?
How many sessions are available during the calendar year (Calendar Year Maximum sessions)?

If William Martin is an approved OUT of network provider, what is the coverage and how is it different from in-network coverage?
What is the address for mailing claims?

Does my insurance cover family or marital therapy? If yes, what is the CPT code and/or an authorization number?

Your responsibility:

Pay any necessary deductible and co-payment at the beginning of each session.

If out of network services, you must pay the full fee at the time of the session, then submit all claims to any other insurance company (other than the three above) and then be reimbursed by your company for your benefits.

Any questions, let me know.