We require 24 hours’ notice to cancel appointments; failure to do so will result in a fee of $50. This fee applies if notification is provided less than 24 hours in advance, or if you or your child do not attend a scheduled clinical visit, including a screening session for group, intake for testing, or appointments scheduled via telehealth/phone. To cancel a scheduled appointment, please contact your provider directly, or call the main number.

Two missed visits without 24 hours’ notice (regardless of reason) may result in loss of regular scheduled appointment time. Two or more missed visits without 24 hours’ notice in a row, or four or more missed visits without 24 hours’ notice (regardless of reason) within a year, may result in termination of services. Please note that tardiness to scheduled session time can similarly disrupt treatment and when repeated may also result in loss of regular appointment time and/or termination of services

For patients 18 years or older, if two or more sessions scheduled with one of our psychiatry providers are cancelled with less than 24 hours’ notice, or not completed, they will be transitioned to their provider’s drop in space windows. Schedules and information pertaining to drop in spaces will be posted in the waiting room.

As you or your child begin clinical care, your provider will discuss with you their recommendations for treatment, including recommended frequency. If you are unable or unwilling to engage in services at the recommended frequency, the provider may not be able to reserve a regular session time, and/or may not be able to continue services.

The Groups Programs offers two no-fee absences for any reason during the fiscal year (July-June), and any absence beyond two, irrespective of advanced notice or reason, results in a $30 fee for insurance billed groups.

Please direct any questions to our Administrative Team reachable at our main number, 617-277-8107.

Description of telehealth

Telehealth is communicating with using an on-line application that provides audio and video communication with a provider using a cellphone or computer. I understand that telehealth will not be the same as a face to face visit due to the fact that I will not be in the same room as my health care provider. My provider will be located in an alternate location that is private and the client also needs to be in a private location. The Center’s telehealth service uses a special application called Zoom. This is a secure web-based system for transmitting video and audio.

Telehealth is used as an alternative to face-to face visits to improve access to care when it is difficult for clients to attend sessions in person, or under circumstances, such as an epidemic, when it may be safer to receive care at home. I understand that telehealth doesn’t replace the potential need for in-person appointments between me and my provider. This determination will be made by my provider.

Privacy

Federal law requires that health care providers protect the privacy and security of my personal health
information. I understand that my provider has undertaken reasonable efforts to provide a system designed to protect the security and privacy of my personal health information using HIPAA-compliant protocols, I understand that my provider will inform me of their location of provider and obtain the location of the patient receiving services.

Technical Problems

During a telehealth session, we could encounter an interruption due to problems with the technology. The most reliable backup plan is to contact one another via telephone. I will make sure to have my phone with me, and will give my clinician that phone number. If we get disconnected from a telehealth session, I will try to restart the session.

Parents of Children/Adolescents

Parents of children or adolescents under the age of 18 need to be present at the start of the telehealth session in order to give consent in person to the visit. Parents of children under the age of 14 need to remain in the home for the duration of the telehealth visit and be accessible if needed.

Emergency Procedures Specific to Telehealth Services

There are additional procedures that we need to have in place specific to Telehealth services. These are for my safety in case of an emergency. If I am having serious symptoms involving my health or safety, or a crisis that we cannot solve remotely, my clinician may determine that I need a higher level of care.

The Center requires an Emergency Contact Person (ECP) who my therapist may contact on my behalf in an emergency. I will write this person’s name and contact information below. If there is an emergency, my clinician may need to call the emergency contact person.

Risks

I understand there are potential risks to this technology, including interruptions, unauthorized access and technical difficulties.  I understand that my health care provider or I can discontinue the telehealth visit if it is felt that the video connections are not adequate for the situation.

• I understand that my telehealth sessions help my provider care for me, but may be different from in person, face-to-face treatment. If the standard of care cannot be maintained using this method of healthcare delivery, my provider will notify me that this is the case and advise me to seek in person care.
• I understand that federal and state law is changing rapidly in response to the COVID-19 epidemic and that this provider will use technology that is allowable by state and federal law. I understand that there are risks and consequences from telehealth, including, but not limited to disruptions or distortions of video and audio transmission due to technical difficulties. Deficiencies or failures of the equipment could result in delay in evaluation or treatment and could affect the treatment session.
• There is potential for unauthorized interruptions by third parties.

Consent

• I agree to inform my clinician of the address where I am at the beginning of every telehealth session, and a phone number to reach me if necessary.
• I have had the alternatives to a telemedicine consultation visit explained to me.
• I can decline the telehealth service at any time without affecting my right to future care or treatment. I can see a provider in person if I decline the telehealth service, but I understand that this visit will need to be scheduled in advance. Any treatment received from my provider prior to receipt of my withdrawal of consent will not be affected.
• I understand that I am responsible for providing equipment and internet or telephone access for telehealth and for arranging a location with sufficient lighting and privacy for my telehealth
  appointments.
• No third parties shall be present or have access to a telemedicine session during its occurrence without my and my provider’s written permission.
• I understand that I will be billed for telehealth sessions and that it will be my responsibility to determine whether my insurance carrier will provide coverage for any treatment I receive, and I will be responsible for full payment in the event that the insurer denies coverage.
• I have had the opportunity to ask questions about the use of telemedicine including the risks and benefits and my provider has answered all of my questions to my satisfaction.

This notice describes how medical information about you may be used and disclosed and how you can gain access to this information. Please review it carefully. If you have any questions about this Privacy Notice, please contact your therapist or our Clinical Director at 617-277-8107.

Understanding Your Health Record/Information

Each time you visit a hospital, healthcare provider, or mental health clinician, a record of your visit is made. Typically, this record contains your symptoms, evaluation and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• basis for planning your care and treatment;
• means of communication among the many health professionals who contribute to your
  care;
• legal document describing the care you received;
• means by which you or a third party payer can verify that services billed were actually
  provided;
• tool in educating health professionals;
• source of information for public health officials charged with improving the health of
  the nation;
• source of data for facility planning and marketing;
• tool with which we can assess and continually work to improve the care we render and
  the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

• better understand who, what, when, where and why others may access your health
  information;
• make more informed decisions when authorizing disclosure to others;
• ensure its accuracy

Your Privacy Rights

You have the following rights regarding the health information that we have about you.

• Your Right to Inspect and Copy: In most cases, you have the right to look at or get copies of your medical records. You may be charged a fee for the cost of copying your records. (You may need to make an appointment to look at your record to assure that we will have it available for you.)
• Your Right to Amend: You may ask us to change your records if you feel that there is a mistake. We can deny your request for certain reasons, but we must give you a written reason for our denial.
• Your Right to Request Confidential Communications by Alternative Means and at Alternative Locations: You have the right to ask that we share information with you in a certain way or in a certain place. For example, you may ask us to send information to your work address instead of your home address. We will do our best to accommodate such a request.
• Your Right to Request Restrictions on Our Use or Disclosure of Information: You can ask for limits on how your information is used or disclosed. We are not required to agree to such requests, but can if we believe it is reasonable to do so.
• Your Right to a List of Disclosures: You have the right to ask for a list of certain disclosures made after April 14, 2003. This list will not include the times that information was disclosed for treatment, payment, or health care operations. The list will not include information provided directly to you or your family, or information that was sent with your permission. It will not include information released without your name or other data that would identify you. The first accounting you request within a twelve month period will be free, but there is a fee for additional requests during the same 12 month period.
• Your Right to a Paper Copy of this Notice. You have the right to obtain a paper copy of this Notice of Privacy Practices at any time. Even if you have agreed to receive this Notice of Privacy Practices electronically, you may still obtain a paper copy. Your requests must be made in writing to us:
  Privacy Officer; The Brookline Center; 43 Garrison Rd; Brookline, MA 02445.

Our Responsibilities

The Brookline Center will:

• maintain the privacy of your health information
• provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
• abide by the terms of this notice
• notify you if we are unable to agree to a requested restriction
• accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us. We will not use or disclose your health information without your authorization, except as described in this notice.

How We Will Use and Disclose Your Health Information

We will use your health information for treatment. 

For example: Information obtained by your therapist, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. These clinicians will document in your record your evaluation and treatment plan. Members of your healthcare team will then record the actions they took and their observations. In that way, we will know how you are responding to treatment. We may also share your health information without your authorization among our clinicians and other staff (including clinicians other than your therapist or principal clinician), who work at The Brookline Center. For example, our staff may discuss your care at a team meeting.

When we make disclosures to a third party (other than your health plan) for coordination or management of your health care, we will usually obtain your written authorization prior to the disclosure. A third party is a person or entity who is not affiliated with our organization. In addition, with your authorization, we will disclose your health information to another health care provider (e.g., your primary care physician or a laboratory) working outside of The Brookline Center.

We will use your health information for payment.

For example: A bill may be sent to you or your health insurance company. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, and the type of visit. Or, as part of the prior approval process, your HMO may request information regarding your current clinical status.

We will use your health information for regular health operations.

The Brookline Center may use and share your health information for activities that are known as health care operations. These are activities that are needed to operate our facilities and carry out our mission. Some of the information is shared with outside parties who perform these health care operations or other services on behalf of The Brookline Center. These are called “business associates”. Business associates must also take steps to keep your health information private. Examples of activities that make up health care operations include:

• contacting you at the address and telephone numbers you give to us (including leaving messages on answering machines) about:
  • scheduled or cancelled appointments, registration/insurance updates, billing or payment matters, or test results
  • information on patient care issues, treatment choices and follow up care
  • other health-related benefits and services that may be of interest to you
• monitoring the quality of care and making improvements where needed
• reviewing medical records for completeness and accuracy
• meeting standards set by regulating agencies
• teaching mental health professionals
• using outside business services; such as storage, auditing, legal or other consulting services
• storing your health information on computers
• managing and analyzing medical information

Uses and Disclosures (Sharing) of Your Health Information Without Your Specific Permission

The Brookline Center may legally use and/or share your health information with others in the following areas without your specific permission. In such cases, we will disclose the minimum amount of information necessary to fulfill our obligation.

• As required by state and federal laws and regulations
• For public health activities, including required reports to the state public health agencies or to agencies such as cancer registries and the federal Food and Drug Administration
• When Brookline Center staff believe you might be in danger of harming yourself or other
  persons or are at risk because of being unable to take care of yourself
• When Brookline Center staff believe that a child, elderly person, or disabled person in your
  care is being abused or neglected
• For health oversight activities such as responding to reviews by government agencies or
  benefit programs such as Medicare or Medicaid
• For research that is approved by a Brookline Center Research Committee when written permission is not required by federal or state law. This also may include preparing for research or telling you about research studies in which you might be interested
• We may disclose health information about you to a court when a judge orders us to do so.
• We may disclose health information about you in legal proceedings without your permission when:
  • your health information involves communications made during a court-ordered psychiatric examination;
  • you introduce your mental or emotional condition in evidence in support of your claim or defense in any proceeding and the judge approves our disclosure of your health information;
  • you file a claim against any of our clinicians or staff for malpractice or initiate a complaint with a licensing board against any of our clinicians;
  • a judge approves our disclosure of your health information in a legal proceeding that involves child custody, adoption or dispensing with consent to adoption;
  • one of our social workers brings a proceeding, or is asked to testify in a proceeding, involving foster care of a child or commitment of a child to the custody of the Massachusetts Department of Social Services.
• For law enforcement purposes under specific conditions such as reporting when someone is the victim of a crime. Other conditions include
  • when the information is provided in response to an order of a court;
  • when you agree to the disclosure
  • we determine that the law enforcement purpose is to respond to a threat of an imminently dangerous activity by you against yourself or another person; or
  • the disclosure is otherwise required by law.
• With regard to people who have died, to coroners, medical examiners and funeral directors, or for organ, eye or tissue donation at death
• To avert a serious threat to health or safety
• For specialized government operations
• As authorized by and as necessary to comply with workers compensation laws

Uses And Disclosures (Sharing) Of Your Health Information That You May Ask To Be Limited, Or Request Not Be Made

In general, the Brookline Center will not give out any information to family or friends without an authorization signed by you. The Brookline Center does not have a patient directory and will not give out any information regarding your care.

In an emergency situation, if you are present and are able to make health care decisions, we will try to find out if you want us to share this information with your family members or others. If you are not able to make your wishes known, we will use our best judgment to decide whether to share information. If it is thought to be in your best interest, we will only share information that others really need to know.

And, if you are not in an emergency situation but are unable to make health care decisions, we will disclose your health information to: your health care agent if we have received a valid health care proxy from you, your guardian or medication monitor if one has been appointed by a court, or if applicable, the state agency responsible for consenting to your care.

Uses And Disclosures Of Information That Require Your Written Permission

• Sharing information about genetic testing (as defined by state law) or genetic test results
• Sharing information about HIV testing or test results
• Sharing information from substance abuse rehabilitation treatment programs
• Sharing information about treatment for sexually transmitted diseases
• Using and sharing health information for research, research preparation, or recruitment, when the appropriate Brookline Center Human Research Committee determines this is required under federal and state laws
• Information which state law recognizes as “privileged” (sensitive) information can only be shared in administrative and judicial proceedings if you give written permission.
  • Privileged (sensitive) information includes information that relates to domestic violence, sexual assault counseling, confidential communications between a patient and a social worker, or confidential details of psychotherapy (from a psychiatrist, psychologist, or licensed mental health nurse clinical specialist)
  • such proceedings may include civil or criminal trials and their preliminary proceedings, or hearings before a state, county or local administrative agency
• Using and sharing psychotherapist notes (notes maintained outside of the medical record for the therapist’s own use); however, specific permission is not required for use or sharing of these notes for your therapist to treat you, for training programs, for legal defense in an action you bring, or for oversight of the therapist

Withdrawing Permission

If you have given permission for your medical information in the above categories to be used or shared, you may withdraw your permission in writing at any time and except to the extent that the providers have already acted on it, we will not make any further disclosures of your information.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with us, contact our Human Rights Officer at 43 Garrison Rd., Brookline, MA 02445. All complaints must be submitted in writing. We will not retaliate against you for filing a complaint. Our Privacy Officer, who can be contacted at 41 Garrison Rd., Brookline, MA 02445, will assist you with writing your complaint, if you request such assistance.

Changes to this Notice

We reserve the right to change the terms of our Notice of Privacy Practices. We also reserve the right to make the revised or changed Notice of Privacy Practices effective for all health information we already have about you as well as any health information we receive in the future. We will post a copy of the current Notice of Privacy Practices at our main office and at each site where we provide care. You may also obtain a copy of the current Notice of Privacy Practices by accessing our website at www.brooklinecenter.com or by calling us at (617)-277-8107 and requesting that a copy be sent to you in the mail or by asking for one any time you are at our offices.

Email and other forms of electronic communication are a very useful way for clients and clinicians to communicate about non-urgent matters. It is important to recognize their limitations. Email should be used only if the arrangement is agreed to by both parties. Prior to using email to
communicate, clients should read our guidelines in full.

Limitations of Email:

• Email is non-secure. Email has the same level of security as a postcard; it passes through servers that are not secure and often monitored. For clients who generate email at work, the content of the email is available, and actually owned by, the employer. Unless the recipient is unusually careful, the email folders on their computer can be accessed by anyone (family, roommates, casual visitors).
• Email should not be used for urgent communication. Clinicians are not expected to monitor their email constantly during the day or night. Therefore, a client should not use email for an urgent or emergency matter.
• It is easy to make mistakes when addressing an email to someone, particularly when address fields are automatically filled in by the email program and can be sent to the wrong addressee. This exposes the sender to the risk of compromising privacy.

I understand and agree to the following:

1. Email should not be used for urgent or emergency communication. For urgent matters, please call the Center’s main number, 617-277-8107.
2. Appropriate use of email includes scheduling appointments, providing educational material or general medical information.
3. Email correspondence with clients is considered part of the clinical record and will be filed in the client’s medical record. Email correspondence will be available to other clinical and administrative staff.
4. Email is neither secure nor private.
5. Staff will use unencrypted emails only for the most routine kind of communication, (appointment scheduling, general advice, educational material).
6. When Center staff send sensitive information (such as diagnostic/evaluation material, clinical issues, or concerns,) these will be sent as an encrypted attachment.
7. Clients are encouraged to use encryption to send information that is of a sensitive nature.

Do not use email to send or request very sensitive information. The Center cannot and does not guarantee the privacy or security of any messages being sent over the Internet