Julie Duncan, Ph.D. is a Psychologist providing a wide range of psychological services to various types of clients. The purpose of the present service is to perform a clinical interview and/or psychological testing. Most testing and assessments are done within one to four hours of time. Psychological testing is usually a one-time experience. Services are provided upon referral from the SSDI office, VES office, or other individual referral sources. Clients scheduled through the SSDI office or VES office are not responsible for payment for their visit. Other client payments are determined based on the referral source. This is a one-time evaluation only and the report will be sent to the appropriate referral source as requested upon completion of the evaluation. Given the type of evaluation based on your referral, no patient/therapist relationship is established. ”

You have a right to withdraw from the evaluation at any time; however, please be aware that this may negatively impact any medical/financial benefits you are receiving or seeking. If you choose this option prior to attaining your goals, it would be appropriate for you to discuss your withdrawal with your client coordinator, your primary counselor, the third party payer, or your physician, etc. who may have prescribed your participation in the service. If you desire a referral to another therapist, this may be accomplished and I will assist you in making the transition

Material that is shared in psychological evaluations is considered confidential to the extent provided by the law. Client information, including case records, is confidential and will be released only under the following conditions:

a).The counselor is using case records for purposes of supervision, professional development, or training and research. In such cases, to preserve confidentially, clients will be identified by first names only;

b). The counselor determines that the client is a danger to himself/herself or to someone else;

c). The client discloses abuse, neglect, or exploitation of a child, elderly, or disabled person;

d). The client discloses sexual contact with another mental health professional with whom the client had/has a professional relationship;

e). The counselor is ordered by a court to disclose information;

f). The client directs the counselor to release the client’s records;

g). The counselor is otherwise required by law to disclose information.

Dr. Duncan has proper training and credentialing for the provision of services that she provides. She has a doctorate degree in Clinical Psychology. It must be mentioned that in this state, by law that psychologists or persons working under the supervision of a psychologist cannot establish and maintain dual relationships. This means if you become a client the relationship that you establish with the therapist cannot extend beyond the boundaries of the therapeutic relationship. For this reason, involvement with clients outside of the boundaries of the therapeutic relationship is strongly discouraged..

If you have a complaint regarding any of the treatment that you receive, please inform Dr. Duncan. If you wish to go beyond this level of complaint, please ask for higher remedies.

I understand that in order to undergo testing/evaluation and/or participate in the evaluation, I am required to sign a Consent for Release of Information form giving Dr. Duncan permission to communicate with my doctors, mental health professionals who have seen me previously and/or any individual or entity directly involved in the payment of my care and/or to obtain copies of records of my previous treatment. I agree to disclose previous mental health treatment and medical care.

With an understanding of the above requirements, I agree to participate in evaluation/testing and release Julie Duncan, Ph.D. from liability for same.

Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner. You can talk to your provider from any place, including your home. You don’t go to a clinic or hospital.

You can talk to your provider from any place, including your home. You don’t go to a clinic or hospital.

Office visits are by appointment only. Please contact the office for an appointment.

• You can stop using telehealth any time, even during a telehealth visit.
• You can still get an office visit if you no longer want a telehealth visit. Please contact the office for availability.

How much does a telehealth visit cost?

• A telehealth visit will not cost any more than an office visit.
• If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits

No. Only sign this document if you want to use telehealth.

If you sign this document, you agree that:

• You agree to participate in the evaluation via telehealth.
• We answered all your questions.
• You want a telehealth visit.

NOTICE OF PRIVACY PRACTICES SUMMARY

This notice is a summary of how your protected health information is used and disclosed and how you can obtain access to this information. You may be provided a full copy of Dr. Duncan’s Notice of Privacy Practices.

Use and Disclosures of Health Information

Dr. Duncan will use health information about you to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.

Dr. Duncan may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, she may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. She provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, she will ask for your written authorization before using or disclosing any identifiable information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any further uses and disclosures.

Dr. Duncan may change these policies at any time. Before making a significant change in our policies, she will change her notice and post the new notice in the waiting area. You can also request a copy of the notice at any time. For more information about Dr. Duncan’s privacy practices, contact Dr. Duncan.

Your Rights

Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522;
• Obtain a paper copy of the Notice of Privacy Practices upon request;
• Inspect and obtain a copy of your health record as provided for in 45 CFR 164. S24;
• Amend your health record as provided in 45 CFR 164.526;
• Obtain an accounting of disclosures of your health information as provided in 45 CFR 104.528;
• Request communications of your health information by alternative means or at alternative locations;
• Revoke your authorization to use or disclose health information except to the extent that action has already been taken.

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights

Complaints

If you are concerned that Dr. Duncan has violated your privacy rights, or you disagree with a decision she made about access to your records, you may send a written complaint to the U.S. Department of Health and Human Services. Dr. Duncan can provide you with the appropriate address upon request.

Our Legal Duty

Dr. Duncan is required by law to protect the privacy of your information, provide this notice about her information practices, and follow the information practices that are described in this notice. If you have any questions or complaints, please contact Dr. Duncan.

WRITTEN ACKNOWLEDGEMENT

I acknowledge that I have reviewed the Notice of Privacy Practices, which provides a description of information uses and disclosures. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that Dr. Duncan is not required to agree to the restrictions I request.