Psychotherapy is not easily described in general statements.
It varies depending on the personality of both the therapist and the patient and the particular problems that the patient
brings. There are a number of different approaches that can be utilized to treat the problems you hope to address. It is not
like visiting a medical doctor, in that it requires a very active effort on your part. In order to be successful, you will
have to work both during our sessions and at home.
Psychotherapy has both benefits and risks. Risks sometime include
experiencing uncomfortable levels of feelings like sadness, guilt, anxiety, anger and frustration, loneliness and helplessness.
Psychotherapy often requires recalling unpleasant aspects of your history. Psychotherapy has also been shown to have benefits
for people who undertake it. It often leads to a significant reduction of feelings of distress, and better relationships and
resolutions of specific problems, but there are no guarantees about what will happen.
You can expect that I will
share how I understand the problems you’ve brought to my attention, how I would go about treating them, what other approaches
I am aware of, the advantages/disadvantages of each, and, to the best of my knowledge, what might happen without treatment.
Sessions are scheduled for 50 or 90 minutes.
You will be expected to pay for each session at the time it is held or, if you prefer, you may pay in advance
for any number of sessions. You will also be expected to pay for any session that is not canceled at least 48 hours in advance.
There are times during the course of treatment that for urgent, personal
or professional reasons one must cancel a therapy appointment. Since you are reserving an hour per week in my schedule, there
is a limit to the number of on time (48 hour) “no-charge” cancellations. The maximum number of on-time cancellations
without a charge is five times. Thereafter, you will be expected to pay for the hour you are reserving for treatment unless
you have made other arrangements with me sufficiently in advance.
do not accept insurance reimbursement as a form of payment. If you have a health insurance policy that provides coverage for
some or all of your mental health treatment, you will be expected to pay for your services with me up front and then request
reimbursement directly from your insurance company. I am happy to assist you in completing any necessary forms in this regard.
Be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis and, in rare cases, a
copy of your entire mental health record. All insurance companies claim to keep such information confidential, but once it
is in their hands, I have no control over what they do with it. It is important to remember that you always have the right
to pay for my services yourself (and not request reimbursement from your health insurance company) and thereby avoid the complexities
that are described above.
My telephone is answered by a voice mail system,
which I monitor frequently. I will make every effort to return your call on the same day you make it, with the exception of
weekends and holidays. If you are difficult to reach, please leave some times when you will be available. If I am unavailable
for an extended time due to vacation, illness, or any other reason, I will provide you with the name of a trusted colleague
whom you can contact if necessary.
BREAKS IN TREATMENT
Occasionally, I may be unavailable
to meet with you for a brief period of time due to vacations, illness, or professional leave. When I take time away from my
practice, I will provide you with substantial advance notice of the break in treatment and I will always provide you with
the name and number of a colleague who will be providing coverage for me during my absence.
Both law and the standards of my
profession require that I keep appropriate treatment records. You are entitled to receive a copy of the records, unless I
believe that seeing them would be emotionally damaging, in which case, I will be happy to provide them to an appropriate mental
health professional of your choice. Because these are professional records, they can be misinterpreted and/or can be upsetting,
so I recommend that we review them together so that we can discuss what they contain.
In general, the confidentiality of communications between a patient and a psychologist is protected by law, and I can only
release information about our work to others with your written permission. However, there are a number of exceptions.
In most judicial proceedings, you have the right to prevent me from providing any information about your treatment. However,
in some circumstances such as child custody proceedings and proceedings in which your emotional condition is an important
element, a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it. There
are some situations in which 1) I am legally required to take action to protect others from harm, even though that requires
revealing some information about a patient’s treatment. 2) If I believe that a child, an elderly person, or a disabled
person is being abused, I must file a report with the appropriate state agency. 3) If I believe that a patient is threatening
serious bodily harm to another, I am required to take protective actions, which may include notifying the potential victim,
notifying the police, or seeking appropriate hospitalization. 4) If a patient threatens to harm him/herself, I may be required
to seek hospitalization for the patient, or to contact family members or others who can help provide protection.
These situations have rarely arisen in my practice. Should such a situation occur, I will make appropriate efforts to fully
discuss it with you before taking any action.
Notice of Privacy Practices by Dr. Samuel Jinich
I am committed to
protecting medical/mental health information about you. As part of my standard practices, I create a record of the care and
services you receive by me for use in your care and treatment.
• I am required by law to make sure your mental
health information is protected. Please review the following important information:
An Introduction to
Privacy Rights for Psychology Clients
You may have heard about the complex new federal privacy rule under the
Insurance Portability and Accountability Act, better known as HIPAA. It is important
that, as my client,
you understand what this rule means, and how it could affect you.
In general, HIPAA establishes requirements for how
I -- as well as other health care
professionals and organizations -- use and disclose your records. HIPAA also provides
certain basic privacy rights and helps clarify all patient privacy rights, including those
that exist under state law.
Following is a brief summary of the HIPAA rule. I will also be providing you with a
detailed notice of your privacy
rights, which is a requirement of HIPAA.
Under the HIPAA rules:
• I will exercise even greater care in handling
your records to prevent unauthorized
individuals from seeing them.
• You generally have the right to review
your records, receive a copy of them, and
request that any errors be corrected. In certain situations, I have the right
• You have increased protection from insurance companies and others who may ask
see your records.
• You are able to request certain restrictions on the disclosure of your records –
I may use my best judgment about whether to comply with your request.
• You have the right to receive confidential
communications of health information
at any location you specify. For example, a client may request that a bill be sent
an address other than his or her home, or ask me not to leave any messages on a
home answering machine.
assured that I consider maintaining my clients’ privacy a critical component of my
practice. Please don’t
hesitate to let me know if you have any questions about the new
HIPAA privacy rule.
. . . . . . . . . . . . . . . . . . . .HIPAA Disclosure . . . . . . . . . . . . . . . . . . . .
Notice of Psychologists’ Policies and Practices to Protect the Privacy of Your Health Information
THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
I. Uses and Disclosures for Treatment, Payment, and Health
I may use or disclose your protected health information (PHI), for treatment, payment, and health
care operations purposes with your consent. To help clarify these terms, here are some definitions:
refers to information in your health record that could identify you.
• “Treatment, Payment and Health
– Treatment is when I provide, coordinate or manage your health care and other services
related to your health care. An example of treatment would be when I consult with another health care provider, such as your
family physician or another psychologist.
- Payment is when I obtain reimbursement for your healthcare. Examples of
payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility
- Health Care Operations are activities that relate to the performance and operation of my practice. Examples
of health care operations are quality assessment and improvement activities, business-related matters such as audits and administrative
services, and case management and care coordination.
• “Use” applies only to activities within
my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
“Disclosure” applies to activities outside of my [office, such as releasing, transferring, or providing access
to information about you to other parties.
II. Uses and Disclosures Requiring Authorization
I may use or disclose
PHI for purposes outside of treatment, payment, and health care operations when your appropriate authorization is obtained.
An “authorization” is written permission above and beyond the general consent that permits only specific disclosures.
In those instances when I am asked for information for purposes outside of treatment, payment and health care operations,
I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before
releasing your psychotherapy notes. “Psychotherapy notes” are notes I have made about our conversation during
a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These
notes are given a greater degree of protection than PHI.
You may revoke all such authorizations (of PHI or psychotherapy
notes) at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have
relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and
the law provides the insurer the right to contest the claim under the policy.
III. Uses and Disclosures with Neither
Consent nor Authorization
I may use or disclose PHI without your consent or authorization in the following circumstances:
Child Abuse: If I have reasonable cause to believe that a child has suffered abuse or neglect, I am
required by law to report it to the proper law enforcement agency or the Washington Department of Social and Health Services.
Adult and Domestic Abuse: If I have reasonable cause to believe that abandonment, abuse, financial exploitation,
or neglect of a vulnerable adult has occurred, I must immediately report the abuse to the California Department of Social
and Health Services. If I have reason to suspect that sexual or physical assault has occurred, I must immediately report to
the appropriate law enforcement agency and to the Department of Social and Health Services.
Oversight: If the California Board of Psychology subpoenas me as part of its investigations, hearings or proceedings relating
to the discipline, issuance or denial of licensure of state licensed psychologists, I must comply with its orders. This could
include disclosing your relevant mental health information.
Judicial or Administrative Proceedings:
If you are involved in a court proceeding and a request is made for information about the professional services that I have
provided to you and the records thereof, such information is privileged under state law, and I will not release information
without the written authorization of you or your legal representative, or a subpoena of which you have been properly notified
and you have failed to inform me that you are opposing the subpoena, or a court order. The privilege does not apply when you
are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is
Serious Threat to Health or Safety: I may disclose your confidential mental health information
to any person without authorization if I reasonably believe that disclosure will avoid or minimize imminent danger to your
health or safety, or the health or safety of any other individual.
Worker’s Compensation: If you
file a worker's compensation claim, with certain exceptions, I must make available, at any stage of the proceedings, all mental
health information in my possession relevant to that particular injury in the opinion of the California Department of Labor
and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.
Patient's Rights and Psychologist's Duties
• Right to Request Restrictions –You
have the right to request restrictions on certain uses and disclosures of protected health information about you. However,
I am not required to agree to a restriction you request.
• Right to Receive Confidential Communications
by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications
of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you
are seeing me. Upon your request, I will send your bills to another address.)
• Right to Inspect and Copy
– You have the right to inspect or obtain a copy (or both) of PHI and psychotherapy notes in my mental health and billing
records used to make decisions about you for as long as the PHI is maintained in the record. I may deny your access to PHI
under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you
the details of the request and denial process.
• Right to Amend – You have the right to request an
amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. On your request, I will discuss
with you the details of the amendment process.
• Right to an Accounting – You generally have the
right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described
in Section III of this Notice). On your request, I will discuss with you the details of the accounting process.
Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request, even if you have
agreed to receive the notice electronically.
• I am required by law to
maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify
you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my
policies and procedures, I will date and post a copy of the revisions to http://www.samueljinich.com.
V. Questions and
If you have questions about this notice, disagree with a decision I make about access to your records, or
have other concerns about your privacy rights, you may contact me, Samuel Jinich, Ph.D. at (415) 474-6414.
If you believe
that your privacy rights have been violated and wish to file a complaint with me/my office, you may send your written notice
of your complaint to me, Samuel Jinich, Ph.D.; 1902 Webster Street; San Francisco, CA 94115.
You may also send a written
complaint to the Secretary of the U.S. Department of Health and Human Services. I will be happy to provide you with the appropriate
address upon request.
You have specific rights under the Privacy Rule. I will not retaliate against you for exercising
your right to file a complaint.
This notice will
go into effect on August 1, 2005.
I reserve the right to change the terms of this notice and to make the new notice provisions
effective for all PHI that I maintain. Revisions to this notice will be posted to this website at the time of revision. I
will be happy to provide you with a written copy of these revisions upon request.
2013 HIPAA Final Rule:
- Most uses and disclosures of psychotherapy notes, uses
and disclosures of protected health information (PHI) for marketing purposes, and disclosures that constitute a sale of PHI
require patient authorization;
- Other uses and disclosures not described in the Privacy Notices will be made
only with authorization from the individual;
- Patients have the right to restrict certain disclosures of PHI
to health plans/insurance companies if the patient pays out of pocket in full for the health care service; and
patients have the right to be notified following a breach of unsecured protected health information.