Description
The Documentation Wizard Practice Management Forms Package covers the ethical and legal obligations and procedures not covered by the Essential Informed Consents and Policies Package. These forms help build trust between you and your client by providing transparency into client rights and responsibilities, fees, information sharing, and your needs as a clinician. They are written to federal standards and have been extensively reviewed and approved by two attorneys, a bioethicist, and a medical editor.
The Documentation Wizard Practice Management Forms Package includes:
- Therapist Paperwork Checklist
- Client Welcome Letter
- Initial Intake Form
- HIPAA: Notice of Privacy Practices
- Client Rights and Responsibilities
- Good Faith Estimate for Behavioral Health
- Release of Medical Information
- Fax Cover Sheet
- Two Case Closure Letters (general and no-show)
- Collateral Communication Letter
- Business Associates Agreement
Customization
Because each therapy practice is different, these forms can and should be customized reflect your practice needs and state requirements. Areas that may need to be customized are highlighted in yellow. You may make any changes needed other than the copyright. These documents are not a substitute for legal advice.
THERAPIST PAPERWORK CHECKLIST
There are up to 12 documents new clients need to complete and bring to their first session. Keeping track of what you need to send can be daunting. This checklist will help you organize and manage this process. Many of these documents need to be sent yearly. So, we’ve even provided a way to keep track of the yearly renewals. When paperwork can seem more important than the therapeutic relationship, we try to streamline the paperwork process so your attention can be on your clients.
CLIENT WELCOME LETTER
Starting therapy is both courageous and anxiety provoking. This letter welcomes your client and explains what they can expect to happen during their first session. It also gives them a list of all the documents they need to fill out and bring to their first session and an estimate of the amount of time they will need to spend doing it. This way, they can plan their time. There are up to 12 documents new clients need to complete before starting therapy, so this estimate is a thoughtful way to welcome them.
INITIAL INTAKE FORM
If you offer a screening call for potential clients, using this form covers all the bases. It includes:
- Client contact information
- Referral source
- Reason for seeking services
- Payment options
- Insurance information
- Client fee (if private pay)
- Rationale for reduced fee (if necessary)
- Outcome of call
HIPAA: NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION (PHI)
The Health Insurance Portability and Accountability Act (HIPAA) is a law that requires the therapist to provide the Notice of Privacy Practices for Protect Health Information (PHI). HIPAA requires a client signature acknowledging that the client has read and been provided a copy of this notice.
This notice describes:
- Confidentiality and Limits to Confidentiality
- The therapist’s legal obligations involving legal issues; a subpoena, court order, agency requests for records, and other requests for the PHI
- Permitted and required uses and disclosures of the client’s PHI
- The 13 client rights with respect to their PHI and limitations to their rights
- How to file a complaint
CLIENT RIGHTS AND RESPONSIBILITIES
Client Rights and Responsibilities is a foundational document in mental health treatment. Its purpose is to clarify client rights, define responsibilities, promote mutual understanding, and enhance accountability. It is not a required document in all states, but it is best practice.
This document covers:
- 14 client rights to treatment
- The 3 rights to be free of mistreatment
- The rights to client confidentiality and 8 limits of confidentiality
- The 7 rights regarding informed consent
- How to file a complaint
- 12 Client responsibilities
GOOD FAITH ESTIMATE FOR BEHAVIORAL HEALTH CARE
In accordance with the No Surprises Act, all healthcare providers are required to notify clients of their Federal rights and protections against potential “surprise billing.” This notice is used when
- the therapist does not take insurance,
- the client chooses not to use their insurance and chooses to pay “out of pocket,” and
- the client is uninsured.
The Good Faith Estimate needs to be sent to clients yearly or whenever you change your fee.
The Good Faith Estimate includes four forms:
- A cover letter to send to your clients explaining the purpose of the law and the forms
- The Good Faith Estimate for Behavioral Health Care
- The Good Faith Estimate and Disclaimer includes a model disclosure to see how to complete it
- The Good Faith Estimate Notice to post on your website or in your office
They were developed:
- With user-friendly language
- With content in keeping with a psychotherapy practice rather than a hospital or clinic
- To comply with the Federal requirements.
RELEASE OF MEDICAL INFORMATION (ROI)
A release of information (ROI) is a legal document that authorizes the disclosure of personal health information (PHI), such as medical or financial records. The ROI is signed by the client or their legal representative and allows a therapist to provide the information to specific individuals.
The Documentation Wizard Release of Medical Information specifies what mental health information can be shared, with whom, and for what purpose. It also includes a place to explain why a client decides not to sign the ROI. Every aspect can be customized with checkboxes and short answers.
FAX COVER SHEET
Even if the fax service being used is encrypted, uses 2-factor authentication, and are HIPAA compliant, they need a disclaimer in case the number has been misdialed or falls into the hands of someone for whom it is not intended.
This sheet:
- Includes a disclaimer in case the fax is received by an unintended recipient.
- Describes what to do in case the fax is received by an unintended recipient
CASE CLOSURE LETTERS
A case closure letter formally documents the end of the therapeutic relationship. It establishes a clear record of treatment and its conclusion. The purpose is to help the client feel empowered to manage their wellbeing after therapy.
There are two Documentation Wizard Case Closure Letters:
- When the client has been a no-show
- When termination is planned
Both case closure letters use friendly language and include:
- Reason for termination
- The date of termination
- Recommendations for aftercare
- 3 ways to find another therapist
- And more…
COLLATERAL COMMUNICATION LETTER
Collateral communication refers to the sharing of information between the therapist and other healthcare professionals involved in the client’s care. It helps ensure continuity of care. Communicating with the client’s PCP and prescriber is required.
This letter is designed:
- To streamline the communication process
- With a combination of checkboxes and short narratives
- To cue the therapist to include information like the diagnosis, engagement with treatment, potential risk, treatment goals (and more)
- So the therapist can express concerns and ask questions
- To give the other provider the information they need to be effective
BUSINESS ASSOCIATES AGREEMENT (BAA)
Any mental health provider who uses a third-party vendor to perform services involving client data (like a telehealth platform, billing services, housekeeping services, an electronic medical record, or tech support) and may have access to client information, must have a Business Associates’ Agreement that reinforces HIPAA. The Documentation Wizard BAA was written specifically for psychotherapists and is meant to be customized with the name of each party engaged in the agreement.
The document includes the HIPAA compliance requirements of
- Permitted uses of PHI
- Required safeguards to protect PHI
- Each party’s liabilities
- Consequences for non-compliance