When fees for services are not paid in a timely manner, various methods may be utilized in collecting unpaid debts. The specific content of the services (e.g., diagnosis, treatment plan, case notes, testing) is not disclosed. If a debt remains unpaid it may be reported to credit agencies, and the clientís credit report may state the amount owed, time frame, and the name of the clinic.

Insurance companies and other third-party payers are given information that they request regarding services to clients. Information which may be requested includes type of services, dates/times of services, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries. This information is only given upon written request and to supply them with information needed to process claims and to approve further or additional treatment services. If you request, we will notify you prior to the release of any of your information. Please note that certain demographic and diagnosis information is released to permit your insurance company to pay for the services that Dr. Garlock has rendered. Information about clients may be disclosed in consultations with other professionals in order to provide the best possible treatment. In such cases the name of the client, or any identifying information, is not disclosed. Clinical information about the client is discussed when you are referred or when you request that information be sent to another provider. When couples, groups, or families are receiving services, a joint file is kept for individuals for information disclosed that is of a confidential nature. The information includes (a) testing results, (b) information given to the mental health professional not in the presence of other person(s) utilizing services, (c) information received from other sources about the client, (d) diagnosis, (e) treatment plan, (f) individual reports/summaries, and (h) information that has been requested to be separate. The material disclosed in conjoint family or couples sessions, in which each party discloses such information in each otherís presence, is kept in the client of records file in the form of case notes and clinical data. In the event in which the clinic or mental health professional must telephone the client for purposes such as appointment cancellations or reminders, or to give/receive other information, efforts are made to preserve confidentiality. Please tell us where we may reach you by phone and how you would like us to identify ourselves. For example, you might request that when we phone you at home or work, we do not say the name of the clinic or the nature of the call, but rather the mental health professionalís first name only. If this information is not provided to us during the intake process, we will adhere to the following procedure when making phone calls: First we will ask to speak to the client (or guardian) without identifying the name of the clinic. If the person answering the phone asks for more identifying information we will say that it is a personal call. We will not identify the clinic (to protect confidentiality). If we reach an answering machine or voice mail we will follow the same guidelines.

I also understand that all electronic transmission of data is covered by these policies and procedures. I understand that all efforts will be taken by Dr. Garlock to maintain my information in a confidential manner and that I can inquire at any time about the confidentiality of my information and clinical record.

I agree to the above limits of confidentiality and understand their meanings and ramifications and agree to these policies during the time that I am in treatment with Dr. Garlock..