DISCLOSURE STATEMENT



Dr. Shantay S. Coleman, MS, PhD.
SSC Neuropsychological Therapy Group PLLC
100 N HOWARD ST STE W, SPOKANE,
WA, 99201-0508, UNITED STATES
sscnptg@companymusical.art
(253) 364-1808
https://neuropsychologicaltherapy.livewebsitedesign.com/

 

 

Independent Practice:

I am an independently contracted provider participating in the Mindful Therapy Group Organized Health Care Arrangement (OHCA). While I have engaged Mindful Therapy Group, P.C., a Washington Professional Services Corporation (Mindful Therapy Group), to provide business administrative services to my behavioral healthcare business, all services you receive from me reflect my own health care license, independent business, and practice style. Mindful Therapy Group subcontracts with an affiliate company, Mindful Support Services, LLC (Mindful Support Services), to provide a portion of the administrative services.

My License(s), Education and Training

I hold the following license(s) in the indicated state(s): ALPC & Psychological Associate License, in WA/CA
I attended Walden university where I received master’s in science and psychology and PhD in science and clinical psychology, and specializations in Forensic and neuropsychology. When it comes to training, I have received psychological training in the following states Minnesota, Nevada, California, and Washington State. I was a psych nurse at a state psychiatric hospital, I work as an educator, and I have participated in a wide range of psychological training methodologies to become a clinical psychologist. When it comes to the American Psychological Association (APA) Codes of Conduct and Ethics that I am bound by it would be associated with providing competent, quality care, and to do no harm. As a licensed clinician, I am required to participate in continuing education, which this is also a practice that I am bound to, and I belong to many organizations and associational groups to name a few such as APA and MPA psychological associational groups and many more.

Are you being Supervised:

Yes, I am being supervised by Dr. Jamie Posthuma, PhD.
Additional information about my licensure is available at < www.doh.wa.gov>.

Patient Mix

I offer therapy services for <____ (Children, Adolescents, Individuals, couples, and families) ____>. I see clients <5 years to adulthood> years old. I <do/do not> offer case management services, which includes but is not limited to providing paperwork for disability, unemployment, custody, adoption, foster care, car accidents and any type of legal issues. I <Do/Do not> offer therapy for individuals who are court mandated for treatment or seeking treatment in which disclosure of appointments will need to be provided to an outside entity.

Treatment Modality and Therapeutic Orientation:

As a mental Health clinician, I utilize a wide range of methodological approaches to help my patients and clients achieve stabilization of their associated conditions, disorders, and associated signs and symptoms. To name a few methods of approach that I utilize are CBT, DBT, psychoeducational therapy, psychotherapy, and integrative therapy approach.

Therapy has both benefits and risks. During therapy treatment, you the client might notice changes in your symptoms, problems, and functioning. Since we will be exploring challenging territory in your life, you might experience greater difficulty throughout our work. Therapy typically produces benefits over time, but sometimes as you get to the root of tender issues, you may feel them even more acutely than in the past. I cannot offer any promise or guarantee about the results you will experience. However, as you commit yourself to work through your vulnerable issues and build upon your strengths, it is likely that you will see improvements throughout your work and in the future.

New Patients

There will be 1-2 initial visits to ensure proper assessment and thorough evaluation. Appointment(s) are 53 minutes. These appointments will be used to evaluate, educate, and determine a mental health diagnosis. I may want to see you weekly until either your symptoms are alleviated, or your condition is stabilizing. We will work together to determine the best frequency of appointments going forward based on your health, treatment goals and stability of your condition.

Cancelling Appointments

It is our goal to provide you with optimal care, and to do so we would like you to adhere to your appointment time, which is reserved specifically for you. I do not double book clients. In return, I ask that you provide our front office with a minimum of < (24 or 48 hours)> hours’ notice if you are unable to make it to your appointment. Please call our front office staff for all scheduling needs at (425)-640-7009 to ensure prompt attention.

I work with all my clients on a reoccurring, weekly basis. If you cancel several appointments, I will ask that you be removed from your recurring appointment slot and be placed on my on-call list, as repeated cancellations present a barrier to the therapeutic process. If you are on the on-call list, I will reach out to you as appointments become available. If you have repeated no-show appointments, upcoming scheduled appointments may be cancelled.

Requests for Consultation

If you need a consultation outside of a scheduled appointment, please direct your request to me via the email or phone number listed. Mindful Therapy Group administrative staff are not clinically trained and are unable to respond to requests for consultation.

In general, my office hours are 10am to 4pm Monday through Friday. I may not be able to respond to requests for consultation outside of these hours.

Emergencies

I am not available on an emergency basis. If you are experiencing an emergency or are concerned you may be a threat to yourself or others, please dial 911, 988 (an emergency line specific to suicide and mental health crises) or go to the nearest hospital emergency room.

Contact for Administrative/Scheduling Questions

If you have questions about scheduling, billing, or technology, please contact Mindful Therapy Group at:

intake@mindfulsupportservices.com
 425-640-7009
7:00am-7:30pm Monday-Friday
8:00am-4:00pm Saturday-Sunday

Rescheduling Appointments

Mindful Therapy Group and/or I will make every effort to provide you with adequate notice if I will be unavailable for a scheduled appointment.

If you need to reschedule an appointment, the rescheduling request should be made with Mindful Therapy Group, not me. If you need to reschedule an appointment, I ask that you give Mindful Therapy Group at least _72__ hours’ notice in advance of the originally scheduled appointment. Rescheduling requests made without __72_ hours’ advance notice will incur late cancellation fees (see Financial Responsibility section below).

Confidentiality

All information disclosed within appointments is confidential. I keep brief notes of our appointments, but such notes and other information related to these appointments will not be disclosed to anyone except as permitted or required by law.

Notice of Privacy Practices

The Mindful Therapy Group Organized Health Care Arrangement Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information. An electronic copy of the Notice of Privacy Practices can be found here.

Your Rights

You have the following rights:

- To refuse treatment.

- To choose a practitioner and treatment modality which best suits your needs.

- To expect that I have met the qualifications of training and experience required by state law.

- To examine public records maintained by the state authority that licenses me and to have such authority confirm my credentials.

- To obtain a copy of the code of ethics to which I am bound.

- To report complaints to the state authority that licenses me contact Washington State Department of Health
- P.O. Box 47877
- Olympia, WA 98504
- 360-236-3848 | www.doh.wa.gov

- To be informed of the cost of my services before receiving the services.

- To be assured of privacy and confidentiality while receiving services from me (note - the law sometimes permits or requires disclosures of private/confidential information); and

- To be free from free from discrimination because of age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status.


Patient/Parent/Guardian Acknowledgment and Consent to Mental Health Treatment

I (the patient or the patient’s parent legal guardian) have been provided a copy of my (or my child’s) provider’s disclosure statement. I have read and understand the information provided. I consent (or consent on my child’s behalf) to receive mental health services from the provider named in this Disclosure Statement.

Patient Name:                

Patient Date of Birth:   

*If patient is under the age of six-teen years old the patient’s parent or legal guardian must sign below

Signed:                          

Name:                           

Relationship to Patient (e.g., self, parent):   


Provider Acknowledgment


Signed:   

Name:      

Date:        

 

TELEHEALTH CONSENT

By signing below, you hereby consent to receive, or have your child receive, therapy services from me via telehealth. “Telehealth” includes the practice of health care delivery, diagnosis, and treatment consultation using interactive video, audio, and/or data communications.

There are benefits and risks to telehealth. The benefits of telehealth include convenience and continuity of care in times when you are unable to see me in-person. Risks include the risks inherent in transmitting information electronically that include, but are not limited to, breaches of confidentiality, theft of personal information, and disruption of service due to technical difficulties. In the event of a technological failure during a telehealth visit, you agree that I may contact you at the phone number listed below.

It is your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, strangers, and hackers could either overhear our communications or have access to the telehealth technology. To further ensure the confidentiality and security of our communications, you are not permitted to record telehealth appointments.

All fees for telehealth services are the same as for non-telehealth services. You are financially responsible for all services rendered and for the charges associated with late cancellations and missed appointments, where such charges are permitted.

I may determine at some point during my treatment of you that treatment via telehealth is no longer appropriate. If this happens, we will discuss options for in-person care or referrals to other practitioners.

Patient Name:             

Patient Date of Birth:   

*If patient is under the age of six-teen years old the patient’s parent or legal guardian must sign below

Signed:                        

Name:                          

Relationship to Patient (e.g., self, parent):  

 

FINANCIAL RESPONSIBILITY
Insurance Fees

I am in-network with a select number of insurance companies for my services. Please provide full insurance information and your insurance card upon your initial visit (or before, if possible) so we can determine the benefits for which you are eligible. If you have a change in insurance, please let us know as soon as possible.

Your insurance plan may require me to assess you a copayment, coinsurance, or deductible, which these fees may vary depending on your insurance companies’ policy stipulations. Mental health appointments are assigned billing codes on claims that vary based on factors such as appointment length and complexity. As a result, your cost share may vary from visit to visit.

Any cost share is due at the time of service. Mindful Therapy Group staff and I will do our best to estimate your cost share in advance of or at the time of your appointment. However, it is possible that your insurance plan, after reviewing the claim, will determine that your cost share is higher than we estimated. In these situations, Mindful Therapy Group will notify you about any balance due with a monthly statement. In the event we overestimate the cost share, the credit will be applied towards your future visits, unless you specify otherwise.

If your insurance plan requires preauthorization for services, it is your responsibility to obtain this authorization prior to our appointment. If you fail to obtain authorization, all associated charges incurred for services rendered by me and not reimbursed to me or Mindful Therapy Group by your health insurance you the client will be financially responsible for all fees and all associated fees will be collected by the patient or client who received services by the associated provider.

Private Pay (Cash Pay) Fees

• <$120 for Associate and $125-$150 for fully licensed Therapists recommended> per 55-minute session for individuals>
• <$120 for associates and $140-$175 for fully licensed therapists recommended> per 55-minute session for couples/families.>

Case Management Time Fees

Most clinical issues should be shared in our appointment. If calls and case management become excessive, I may need to charge for case management time. I will always inform you prior to providing this service and prior to billing for it.
< ($100 - $150 recommended)> per hour.

Cancellation Fees

For all missed appointments or late cancellations, the patient or client will be responsible for the full session rate.

• < ($full session rate of $120)> for missing session.

This charge is irrespective of the reason for the cancellation/no show. Insurance does NOT cover this fee and will automatically be charged to the credit card listed on file.

While I understand unexpected things sometimes pop up, if there is a pattern noticed of cancelled appointments, I may be unable to continue providing services to you, and I would also like to inform you that one of my practices is to reserve the right to cancel future appointments, which allows us to make room for clients committed to the therapeutic process. I will always communicate about this with you and determine if we’re a good fit prior to making changes to your scheduled appointments.

Collections

If you have an unpaid patient balance of $100 for more than 120 days, the balance may be turned over to a third-party collection agency. You will receive a final courtesy phone call and/or letter to remind you of your balance due. If you believe that there is an error in your billing, please let us know as soon as possible so we can research the issue. Unpaid balances without a payment plan or partial payment initiated after 120 days will initiate a phone collections effort for recovery, and some identifying confidential information will be released in this process. This may negatively impact your credit. It is very important that you update your contact information with us to ensure you are aware of your financial responsibility and receive your statements.

Assignment of Benefits:

By signing below, in exchange for, and in connection with, any and all of the services provided to you or your child, as applicable, by me, your provider, you irrevocably assign and transfer to Mindful Therapy Group and me all of the rights, benefits, privileges, protections, claims and any other interests of any kind whatsoever, without limitation, that you or your child, as applicable, had, have or may have in the future pursuant to or in connection with any insurance policy or plan, health benefit plan, health management agreement, risk-bearing agreement, trust, fund or any other source of payment, insurance, indemnity or health or medical coverage of any kind covering you or your child, as applicable. This assignment also includes assignment of your or your child’s, as applicable, appeal rights, fiduciary rights, rights to sue, rights to payment, rights to full and fair claims review, rights to penalties or interest, rights to plan documents and plan information, and rights to notices and disclosures from any source.

Patient Name:                

Patient Date of Birth:   

*If patient is under the age of sixteen years old the patient’s parent or legal guardian must sign below

Signed:                          

Name:                            

Relationship to Patient (e.g., self, parent):  

 

Leave this empty:

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Document name: DISCLOSURE STATEMENT
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