Service Agreement

Great Lakes Psychology Group PC, Find My Therapist, and its affiliated professionals (collectively, “GLPG Professionals”, “we”, and “our”), operating with support from Great Lakes MSO, LLC (collectively, “Great Lakes Psychology Group”) provide technology-enabled and in-person mental health services. This Agreement describes GLPG Professionals’ services and clinical programs. It is important for you to read this document and discuss any questions you might have with us. Great Lakes MSO, LLC. does not provide clinical services; it performs administrative, payment, and other supportive activities for GLPG Professionals. When you request to receive services from a GLPG Professionals provider those services are outlined by this agreement, as well as the discussions between you and/or your child (also referred to collectively as “you”), and your provider(s). It is important for you to read this document and discuss any questions you might have with your Great Lakes Psychology Group care team. If you agree to these terms we will assume that you have read, understood, and agree to its contents. We reserve the right, at our sole discretion, to change, modify, add or remove portions of these terms, at any time. It is your responsibility to check these terms periodically for changes.

Psychotherapy is not easily described in general statements. It varies depending on the personalities of the provider and patient, and the particular problems you are experiencing. There are various methods your provider may use to deal with the problems that you hope to address. Psychotherapy is not like a medical doctor visit. Instead, it calls for active involvement on your part. In order for the therapy to be most successful, you or your child will have to work on things you talk about with your provider, both during your sessions and at home. Psychotherapy can have risks and benefits. Since therapy often involves discussing unpleasant aspects of your life, you may experience uncomfortable feelings like sadness, guilt, anger, frustration, anxiety and helplessness. Your problems may temporarily worsen after the beginning of therapy. For instance, individuals seeking treatment for anxiety often notice an increase in symptom severity during the first several weeks of therapy as they learn new ways of managing their anxiety. Finally, even with best efforts, there is a risk that therapy may not bring you your desired outcomes. On the other hand, psychotherapy is well-documented to have many benefits. It often leads to better relationships, solutions to specific problems, better problem-solving and coping skills, and significant reductions in feelings of distress. But there are no guarantees of what you will experience. The first few sessions will involve an evaluation of your goals and needs. By the end of the evaluation, your provider will be able to offer you some first impressions of what your work together will include and a treatment plan to follow, if you decide to continue with therapy. You should evaluate this information along with your own opinions of whether you feel comfortable working with your provider. Therapy involves a large commitment of time, money and energy, so please be careful about the provider you select. If you have questions about your provider’s procedures, you and your provider should discuss them whenever they arise. You may, at any time, refuse treatment, request a change in treatment approach, or ask for a referral elsewhere. There are circumstances in which your provider may not be the most appropriate provider for your psychological services. This may occur if your concerns are outside the scope of your provider’s training or expertise, if your working together would create a conflict of interest, or if your provider’s approach to therapy appears not to be working after a reasonable amount of time and effort.
Your relationship with your provider is, and will always remain, professional. All parties will treat each other with respect at all times. You acknowledge that you have been given an opportunity to select a provider from Great Lakes Psychology Group prior to the consult and that you have received information about your provider, including their qualifications and credentials (listed on the provider profile) and that you may ask about a provider’s qualifications and credentials either during appointments, or by contacting Great Lakes Psychology Group. If, at any time, you have concerns or complaints about your treatment, you may direct them to your provider or Great Lakes Psychology Group.

Supervisory Disclosure

If your provider is a limited licensed provider, the provider will be under the supervision of a fully licensed provider of the appropriate discipline as required by state law. To ensure that you receive the highest standard of care, the supervisor will routinely monitor and review the clinical work of your provider. The privacy of your identity, communications, and Clinical Record will be maintained by the supervisor as delineated in the Confidentiality & Privacy Practices section of this Agreement. At your first session, your provider will provide you with the name and contact information of their supervisor.

GLPG Professionals may provide mental health care via telehealth using voice calls, video calls and messaging services. GLPG Professionals may recommend other treatments, as needed. Telehealth includes the practice of psychological health care delivery, psychotherapy, diagnosis, consultation, treatment, referral to resources, education, and the transfer of medical and clinical data.

The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following: (1) a review of health records, and/or test results via asynchronous communications; (2) live two-way interactive audio and video; (3) interactive audio with store and forward; or (4) output data from medical devices and sound and video files. The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

If you and your provider agree to schedule any telehealth appointments, you understand that you have the following rights with respect to telehealth:

• The laws that protect the confidentiality of your personal information also apply to telehealth. As such, you understand that the information disclosed during the course of your sessions is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to, reporting child, elder, and dependent adult abuse; expressed threats of violence toward an ascertainable victim; and where you make your mental or emotional state an issue in a legal proceeding. You also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without your written consent.
• You understand that you have the right to withhold or withdraw your consent to the use of telehealth in the course of your care at any time, without affecting your right to future care or treatment.
• You understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider, that: the transmission of your personal information could be disrupted or distorted by technical failures, the transmission of your personal information could be interrupted by unauthorized persons, and/or the electronic storage of your personal information could be unintentionally lost or accessed by unauthorized persons. Great Lakes Psychology Group utilizes secure, encrypted audio/video transmission software to deliver telehealth.
• You understand that there is a risk that services could be disrupted, delayed, or distorted by unforeseen technical problems beyond the control of Great Lakes Psychology Group. You agree to hold harmless Great Lakes Psychology Group for delays in evaluation or for information lost due to such technical problems.
• In addition, you understand that teletherapy based services and care may not be as complete as face-to-face services. You also understand that if your provider believes you would be better served by another form of therapeutic services (e.g. face-to-face services) you will be referred to a professional who can provide such services in your area.
• In rare events, the provider may determine that the transmitted information is of inadequate quality, thus necessitating a rescheduled telehealth session or a referral to a local psychologist or counselor as applicable.
• You understand the alternatives to counseling through telehealth as they have been explained to you, and in choosing to participate in telehealth, you are agreeing to participate using video conferencing technology. You also understand that at your request or at the direction of your provider, you may be directed to “face-to-face” psychotherapy.
• You understand that you may expect the anticipated benefits such as improved access to care and more efficient evaluation and management from the use of telehealth in your care, but that no results can be guaranteed or assured. You understand that there are potential risks and benefits associated with any form of psychotherapy, and that despite your efforts and the efforts of your provider, your condition may not improve, and in some cases may even get worse.
• You understand that your healthcare information may be shared with other individuals for scheduling and billing purposes.
• You understand that persons may be present during the session other than your provider in order to operate the telehealth technologies. You further understand that you will be informed of their presence in the session and thus will have the right to request the following: (1) omit specific details of your psychological health history that are personally sensitive to you; (2) ask non-clinical/licensed personnel to leave the telehealth session; and/or (3) terminate the session at any time.
• You understand that you have a right to access your medical information and copies of your medical records in accordance with the laws pertaining to the state in which you reside.
• You accept that teletherapy does not provide emergency services. If you are experiencing an emergency situation, you understand that you can call 911 or proceed to the nearest hospital emergency room for help. If you are having suicidal thoughts or making plans to harm yourself, you can call the National Suicide Prevention Lifeline at 1.800.273.TALK (8255) for free 24 hour hotline support. Clients who are actively at risk of harm to self or others are not suitable for teletherapy services. If this is the case or becomes the case in future, your provider will recommend more appropriate services.
• You understand that there is a risk of being overheard by anyone near you if you are not in a private room while participating in teletherapy. You are responsible for (1) providing the necessary computer, telecommunications equipment and internet access for your teletherapy sessions, and (2) arranging a location with sufficient lighting and privacy that is free from distractions or intrusions for your teletherapy sessions. It is the responsibility of the provider to do the same on their end.
• You understand that different states have different regulations for the use of telehealth and that if you travel out of state, you may not be able to receive telehealth services if your provider is not licensed or otherwise authorized to practice psychotherapy in the state where you are physically located.
• You understand that federal and state law requires health care providers to protect the privacy and the security of health information. You understand that Great Lakes Psychology Group will take steps to make sure that your health information is not seen by anyone who should not see it. You understand that telehealth may involve electronic communication of your personal health information to other health practitioners who may be located in other areas, including out of state.

It is important that you establish a plan with your provider in case you experience technological difficulties and get disconnected, or you experience a mental health crisis requiring in-person treatment.

• If you get disconnected due to technological difficulties, your provider will contact you using your information on file with Great Lakes Psychology Group. If you get disconnected during a mental health crisis, your provider will contact you, or if they are unable to reach you, your emergency contact. It is imperative that you ensure your, or your emergency contact’s, information is always up-to-date.

If you need to receive follow-up care, please contact your provider. In the event of an inability to communicate as a result of a technological or equipment failure, please contact Great Lakes Psychology Group at 800-693-1916 and support@glpg.net.

Telehealth care is a flexible and convenient way to get healthcare, but it may not be right for treating certain symptoms or illnesses that need an in-person or urgent care visit.

PLEASE NOTE: OUR SUPPORT TEAM DOES NOT ADDRESS MEDICAL EMERGENCIES. IF YOU OR YOUR CHILD IS EXPERIENCING A MEDICAL EMERGENCY, IS CONSIDERING HARMING THEMSELVES OR OTHERS, OR IS OTHERWISE IN IMMINENT DANGER, YOU SHOULD DIAL 911 AND/OR GO TO THE NEAREST EMERGENCY ROOM.

All laws and protections for in-person medical visits also apply to telehealth visits. This includes confidentiality of information, access to medical records, and sharing of information that could identify you personally.

You may decide that you do not want to use telehealth services for you or your child at any time. This will not make you lose your health program benefits or your rights to future health care.

In order to authorize behavioral health services for your child, you must have either sole or joint legal custody of your child. If you are separated or divorced (or become separated or divorced) from the other parent of your child, you agree to immediately notify the other parent that a GLPG Professional is meeting with your child. You are responsible for ensuring that Great Lakes Psychology Group has the appropriate authorizations needed for the treatment of your child. We may require you to provide, where custody or the right to information about treatment is contested, a copy of the most recent custody decree or other documentation that establishes custody rights of you and the other parent or otherwise demonstrates that you have the right to authorize treatment for your child. If there are any changes in the status of legal guardianship/parent status, you understand that it is your responsibility to promptly notify GLPG Professionals of any such changes.

One risk of child therapy involves disagreement among parents and/or disagreement between parents and the child’s provider regarding the child’s treatment. If either parent with the appropriate authority decides that behavioral health services should end, GLPG Professionals will honor that decision, unless there are extraordinary circumstances. However, in most cases, we will ask that you allow the GLPG Professional the option of having a few closing appointments with your child to appropriately end the treatment relationship.

During the treatment of a child, GLPG Professionals may meet with the child’s parents/guardians either separately or together. Please be aware that GLPG Professionals’ patient is the child – not the parents/guardians nor any siblings or other family members of the child. Furthermore, any communication by a parent to Great Lakes Psychology Group or GLPG Professionals may be legally disclosed to the other parent, unless that parent’s parental rights have been removed. A parent should NOT share any information which they are not willing to have disclosed to the other parent.

In certain cases, the provider’s responsibility to your child may require involvement in conflicts between parents.  By signing the consent form, you agree that the provider’s involvement will be strictly limited to that which will benefit your child. This means, among other things, that you will treat anything that is said in session with the provider as confidential. Neither parent will attempt to gain advantage in any legal proceeding from treatment with your child. You agree that in any such proceedings, neither parent will ask the provider to testify in court, whether in person or by affidavit. You also agree to instruct your attorneys not to subpoena the provider or to refer in any court filing to anything that has been said in treatment. If the provider is required to testify, the provider is ethically bound not to give any opinion about either parents’ custody or visitation suitability. If the provider is required to appear as a witness, the party responsible for the provider’s participation agrees to reimburse at a rate to be determined with the provider in advance for time spent traveling, preparing reports, testifying, being in attendance, and any other case-related costs.

You hereby certify that you have legal authority to authorize GLPG Professionals to provide behavioral health services including psychology and behavioral therapy, and other behavioral health services to your child. You further certify that, if you are a party to or otherwise the subject of any agreement or court order that requires the written approval of the child’s other parent or any third party to authorize behavioral health services for your child, you have provided or will provide that written approval prior to or at the start of treatment.

Information for Minors & Parents

Minor patients who are not emancipated, and their parents should be aware that the law may allow parents to examine their child’s treatment records. They should also be aware that many states have exceptions for sensitive types of treatment, including mental health. Minors can often consent to these at a younger age. When a minor is able to provide consent to (and control access to information about) their own treatment, they are generally also able to receive confidential treatment, although that treatment may be limited to a finite number of sessions. While privacy in psychotherapy is very important, particularly with adolescents, parental involvement is also essential to successful treatment. Therefore, it may be your provider’s policy to request an agreement from any patient under 18 years of age and his/her parents allowing the provider to share general information with parents about the progress of treatment and the child’s attendance at scheduled sessions.

Your participation is important, and is often essential to the success of the treatment. This section is intended to inform you about the risks, rights and responsibilities of your participation as a collateral participant. Your agreement and signature, below, indicates your understanding of your role as a collateral and the limitations therein. If you have any questions or concerns about what it means to be a collateral, and especially if you have questions or concerns about information that may be shared with another parent, it is critical that you discuss these questions/concerns with your GLPG Professionals provider.

Who and what is a collateral?

In the context of Great Lakes Psychology Group, a collateral is usually a parent or caretaker who participates in therapy to assist the child. The collateral is not considered to be a patient and is not the subject of the treatment. In addition to the mental health provider’s primary responsibility being to the patient with respect to treatment, they also have certain legal and ethical responsibilities to patients, and the privacy of that relationship is given legal protection. That privacy protection does not apply to collaterals.

The role of collaterals in therapy

The role of a collateral can vary greatly. For example, a collateral might attend only one appointment, either alone or with the patient, to provide information to the provider and never attend another appointment. In another case a collateral might attend all of the patient’s therapy appointments and their relationship with the patient may be a focus of the treatment. Your child’s provider will discuss your specific role in the treatment at your first meeting and at other appropriate times.

Benefits and risks

Mental health treatment can engender intense emotional experiences, and your participation in your child’s treatment may also cause strong anxiety or emotional distress. It may also expose or create tension in your relationship with your child. While your participation can result in better understanding of your child or an improved relationship, or may even help in your own growth and development, there is no guarantee that this will be the case. If you are participating in your child’s treatment, you should expect the provider to request that you examine your own attitudes and behaviors to determine if you can make positive changes that will be of benefit to your child.

Professional records

No separate medical record or chart will be maintained on you in your role as a collateral. However, your demographic information will be maintained as part of your child’s record, and information you provide may be entered into your child’s chart, if appropriate. Your child and other adults with a right of access to health records may have a right to access the chart and the material contained therein, which may include information and communications you have provided. Other adults with a right of access to the chart / record may also have access to the information / communications you provide. There will not be a diagnosis assigned to you in your role as a collateral and there is no individualized treatment plan for you.

The confidentiality of the things you say to your child’s care team

The confidentiality of information in your child’s chart, including the information that you provide, is protected by both federal and state law. However, as a collateral you are not the patient, but rather you are assisting in the clinical care of a child and are not directly receiving treatment yourself.

Providers specializing in the treatment of children have long recognized the need to treat children in the context of their family. In treatment involving children and their parents, access to information is an important and sometimes contentious topic. Particularly for older children, trust and privacy are crucial to treatment success. But parents also need to know certain information about the treatment. For this reason, your child’s provider may elect to discuss what information will be shared and what information will remain private, in accordance with applicable state law.

Fees and Billable Services

Sessions are billed at rates generally ranging from $100 to $275 depending upon the complexity and length of the visit. You certify that the information given by you for payment purposes is accurate and complete. If you have insurance benefits, session fees will be billed to your insurance and reduced to the rates we have agreed to as a contracted provider with your insurance company. If you have questions about your coverage, you should contact your insurance company directly.

Other services such as written reports, travel time, review of records, communication with other professionals, and services provided by telephone may be charged at an hourly rate as determined by your provider. If you become involved in legal proceedings that require your GLPG Professional’s participation, you will be expected to pay for all of their professional time, including preparation and transportation costs, even if they are called to testify by another party. Legal involvement may be charged at an hourly rate as determined by your GLPG Professional. If you have special financial needs, please discuss these with your GLPG Professional.

“No show” or “late cancel” appointments may also be billed to you as permitted by applicable laws and payor requirements.

Payment Method on File

You will be expected to pay for each session at the time it is held, unless we agree otherwise or you have insurance coverage that requires another arrangement (for example, balances billed to you after insurance processing).

By providing a credit card, debit card, or bank account for payment, you authorize Great Lakes Psychology Group to securely store your payment information and charge your account for any amounts owed, including copayments, coinsurance, deductibles, late cancellation or no-show fees, balances due after insurance processing, and any other charges permitted under this Agreement.

Great Lakes Psychology Group may charge your card or bank account on file for any patient responsibility amounts. Receipts will be provided after each charge, and a single charge may include fees for multiple appointments due to the timing of insurance processing.

Financial Responsibility

Your or, as applicable, your child’s insurance may cover some or all of our services. If you have to pay a deductible, copayment, or coinsurance for health care services, the usual cost-sharing rules will apply.

Insurance benefit verification performed by Great Lakes Psychology Group is provided as a courtesy and is based on information received from your insurance company. Verification of benefits does not guarantee payment. Your insurance company determines eligibility, benefits, and claim payment at the time the claim is processed.

You agree that all people or companies (third parties) who pay any part of your GLPG Professional’s bill shall pay those amounts directly to Great Lakes Psychology Group.

By receiving services, you acknowledge and agree that you are financially responsible for all charges associated with services provided, regardless of insurance coverage, except where prohibited by law or by contractual agreement with your insurance plan.

You remain responsible for payment for all services you receive and must pay Great Lakes Psychology Group any costs not paid by your insurance or other third parties, unless state or federal regulations do not allow this.

Authorizations and Insurance Responsibilities

You agree to provide any required authorization information prior to the start of services. For Employee Assistance Program (EAP) benefits, Great Lakes Psychology Group will only bill sessions from the date a valid authorization is received by our office. You understand that it is your responsibility to ensure that an active EAP authorization is on file before each appointment. Sessions rendered before the authorization is received will not be billed retroactively to the EAP.

If EAP authorization information is provided after services have occurred and your medical insurance has already been billed, you agree to pay any and all cost shares associated with treatment. Great Lakes Psychology Group will only bill EAP claims beginning with the date the authorization is received and forward.

You agree to provide updated medical insurance information at all times and to take any necessary steps to resolve Coordination of Benefits (COB) issues directly with your insurance company. If insurance coverage is not current or COB is not resolved, you understand that sessions may be billed at your provider’s standard private pay rates until insurance payment is received.

If new or corrected insurance information is provided after an insurance company’s timely filing limit has expired (which may be as short as 90 days for some plans) and the claim is denied, you agree to be responsible for payment at private pay rates for the affected services. You may contact your insurance company at any time to request reprocessing of a denied claim if you believe it was processed in error.

Insurance Reimbursement

Many health insurance plans provide coverage for necessary mental health treatment when you see a licensed provider. It is your responsibility to know the limitations and restrictions of your insurance benefits. Note that many policies may only cover a limited number of sessions each year, may have restrictions on the licensure of the provider you see, and may or may not provide payment for a provider considered to be out of network with your health insurance plan.

Please check your coverage carefully prior to your first session. Our staff will provide whatever information we can based on our experience and will be happy to help you understand the information you receive from your insurance company. You may call the number on your insurance card and ask questions such as:

• Do I have benefits for outpatient mental health services?
  • Do I have coverage when I see an out-of-network provider?
  • How much is my deductible and has it been met this year?
  • Is there a separate deductible for mental health services?
  • What is my copay or coinsurance for mental health services?
  • What are the allowable amounts for procedure codes 90791 (diagnostic evaluation), 90834 (psychotherapy, 37–52 minutes), and 90837 (psychotherapy, 53+ minutes)?

Insurance claims will be submitted to your health insurance company by Great Lakes Psychology Group. If your provider or your insurance company determines that your psychotherapy is not “medically necessary” according to the guidelines of the insurance industry, you will be responsible for the fee, as insurance covers only services deemed medically necessary.

You should also be aware that your contract with your health insurance company requires that we provide information relevant to the services we provide to you. We are required to provide a clinical diagnosis and may be required to provide additional clinical information such as treatment plans, summaries, or copies of your Clinical Record. In such situations, we will make every effort to release only the minimum information necessary. Once information is provided to your insurance company, we have no control over how that information may be stored or used by the insurer. By signing this Agreement, you authorize Great Lakes Psychology Group to provide requested information to your insurance carrier.

You always have the right to pay for services yourself to avoid the issues described above (unless prohibited by contract), and we can provide you with a statement that you may submit directly to your insurance company for reimbursement if applicable.

Collections and Nonpayment

If there have been no payments on your account for more than 60 days and arrangements for payment have not been agreed upon, we may use legal means to secure payment. This may involve hiring a collection agency or pursuing payment through small claims court, which may require disclosure of limited information regarding your treatment.

In most collection situations, the only information we release regarding a patient’s treatment is the patient’s name, the nature of services provided, and the amount due.

If a payment is returned, declined, or disputed with your bank or credit card company, you remain responsible for the original charge and any applicable fees permitted by law. Great Lakes Psychology Group reserves the right to suspend scheduling of future appointments until outstanding balances are resolved.

If you have questions about fees, payments, or your balance, please speak directly with your provider, contact us at support@glpg.net, or call (800) 693-1916.

Good Faith Estimate

If you are uninsured or not using insurance, you may receive a Good Faith Estimate of expected charges for services as required by federal law under the No Surprises Act.

Refund Eligibility

Refunds that Great Lakes Psychology Group is able to confirm are owed will be paid for services that were overpaid, duplicate payments, inaccurate billing, services that were not rendered, or insurance should have been billed. Refunds are subject to verification and approval by Great Lakes Psychology Group’s billing department.

Requesting a Refund

To request a refund, you must contact our billing department within 30 days from the date of the original payment or the discovery of the overpayment or non-rendered service. Refund requests can be made by contacting our billing department directly at support@glpg.net. Please provide accurate and complete information, including your name, contact details, payment details, a brief explanation for the refund request, and any relevant supporting documentation.

Requesting a Refund

To request a refund, you must contact our billing department within 30 days from the date of the original payment or the discovery of the overpayment or non-rendered service. Refund requests can be made by contacting our billing department directly at support@glpg.net. Please provide accurate and complete information, including your name, contact details, payment details, a brief explanation for the refund request, and any relevant supporting documentation.

Refund Processing

Upon receipt of your refund request, we will review the request and initiate the refund process if it meets the eligibility criteria. Refunds will be processed within approximately 5-10 business days from the date of approval. Refunds will be issued using the same payment method used for the original payment, unless otherwise specified and approved by our billing department. Whether or not to grant a refund request is solely within the discretion of our billing department.

Refund Denial

We reserve the right to deny refund requests. Refund requests submitted after the 30-day timeframe will not be considered, unless there are extenuating circumstances deemed acceptable by our billing department.

No Refunds for Services Rendered.

Refunds will not be issued for services that have been rendered in accordance with the agreed-upon treatment plan or for any charges that are non-refundable for any reason including, but not limited to applicable law, regulation, guidance, or agreement. Any disputes regarding services rendered should be addressed separately in accordance with our patient dispute resolution process.

Modifications to the Refund Policy

We reserve the right to modify or amend this refund policy at any time without prior notice. Any changes to the refund policy will be effective immediately upon posting the revised Agreement on our website or other appropriate channels.

We understand you may have to reschedule or cancel an appointment from time to time. Each GLPG Professional sets their own cancellation policy for their practice — it isn’t determined by GLPG. A cancellation policy is an agreement between you and your provider that outlines how much will be charged if you cancel within a certain window of time (typically 24 to 48 hours before the appointment). You may be charged for appointments that are not canceled between 24 to 48 hours in advance, and appointments to which you are late by 15 or more minutes, as specified by your GLPG Professional and to the extent permitted under applicable laws or payor requirements. You can find these specific fees and required cancellation window in your appointment reminder notifications. You can also discuss this with your GLPG Professional during your first appointment.

No-shows and late-cancellations cause problems that go beyond a financial impact. Changes less than 24-48 hours in advance lead to appointment slots that are difficult to fill. Without ample notice, cancellations prevent others from being able to schedule into that time slot.

If you repeatedly miss scheduled appointments, and if GLPG Professionals are unable to contact you for a period of time, you understand that your agreement with GLPG may be terminated and you will be removed from GLPG’s platform.

The law protects the privacy of all communications between a patient and a provider. We must follow federal healthcare privacy and security laws and protect your health information. We work hard to make sure that your personal information is secure. We use standard physical, electronic, and business security methods (such as encryption) to help prevent access to your health information by people who should not see it. But we cannot promise that data sent over the Internet or through a data storage facility will be perfectly secure. So, although we try to protect your personal information, we cannot guarantee the security of any information you send to us. You can read more information about our use of health information and other personal information in our Notice of Privacy Practices (“NPP”): https://www.greatlakespsychologygroup.com/hipaa/

In most situations, we can only release information about your treatment to others if you sign an Authorization form that meets certain legal requirements imposed by state law and/or HIPAA. However, your signature on this Agreement provides consent that we may disclose information in the following situations:

• We may communicate with another health care provider within the organization in order to coordinate continuity of care if necessary. This includes sharing clinical information with a provider who may be providing temporary coverage while your usual provider is out of the office.
• We may occasionally consult with other health or behavioral health professionals about a case. Should your provider seek such consultation, they will make every effort to avoid revealing your identity. These other professionals are also legally bound to keep any information confidential. Unless you object, they will not tell you about these consultations unless they feel that it is important to your work together.
• We may access your Clinical Record for administrative and operations purposes, including but not limited to billing insurance, conducting peer review or quality assurance activity, supervision, or for a purpose expressly authorized by the patient. Staff is trained to protect your privacy and will not release any information without permission. This may include information relating to genetic tests, substance abuse, mental health, communicable diseases and other health conditions.
• We are allowed to disclose information to your health insurance company to bill your sessions or to collect past due fees.
• With other individuals involved in your care such as caregivers or family members where we have permission to do so, or in the event of a mental health crisis or other emergency.

There are some situations where we are permitted or legally required to disclose information without either your consent or Authorization:

• If you are involved in a court proceeding and a request is made for information about the professional services we provided you and the records thereof, such information is usually protected by the provider-patient privilege law. Whether we provide any information depends on 1) your written authorization; 2) you informing us that you are seeking a protective order against our compliance with a subpoena that has been properly served on your provider and of which you have been notified in a timely manner; or 3) a court order requiring the disclosure. If you are involved in or contemplating litigation, you should consult with your attorney about likely required court disclosures.
• If a government agency is requesting the information for health oversight activities, we may be required to provide it to them.
• If you file a complaint or lawsuit against us, we may disclose information as relevant for our defense.
• If you file a worker’s compensation or automobile insurance claim, and your treatment is relevant to the injury involved in your claim, we must, upon appropriate request, provide information necessary for utilization review purposes.
• If your provider has reasonable suspicion that a child has suffered abuse or neglect, the law requires that the provider file a timely report with the appropriate government agency.
• If your provider has reasonable cause to believe that abandonment, abuse, financial exploitation, or neglect of a vulnerable adult has occurred, the law requires that the provider file a report with the appropriate government agency.
• If your provider has reason to believe that you or someone else is in imminent danger, your provider may be required by law to take protective actions, including notifying potential victims, contacting the police, seeking hospitalization for you, or contacting family members or others who can provide protection.
• As otherwise permitted in our NPP and by applicable law.

In any of the above situations, we will make an effort to discuss it with you before taking action and we will limit our disclosure to what is necessary.

In the event that support group sessions are provided, you are expected to keep materials shared in the group confidential. We cannot be held responsible for a breach of confidentiality on the part of group members.

While this written summary of exceptions to confidentiality should prove helpful in informing you about potential disclosures, it is important that you discuss any questions or concerns that you may have now or in the future with your provider. The laws governing confidentiality can be quite complex. In situations where specific advice is required, formal legal advice may be needed.

By accepting this agreement, you agree to let us share your records as described above and acknowledge receipt of the NPP.

Communication Consent

Email and text messaging allow Great Lakes Psychology Group to exchange information efficiently for the benefit of patients. As part of providing services, we may communicate with you for purposes such as appointment reminders, scheduling updates, announcements, and other important information related to your care.

By providing your phone number to Great Lakes Psychology Group, you agree to receive communications via phone call and/or text message, which may include calls or texts sent using an automated system, from or on behalf of Great Lakes Psychology Group and/or your Great Lakes Psychology Group-affiliated provider. These communications may relate to account registration, your appointment, rebooking cancelled appointments, insurance claim status, insurance and payment information, and treatment.

Service-Related SMS/Text and Email Communications

Service-related communications may include appointment reminders and confirmations, updates or changes to scheduled appointments, rebooking notifications for cancelled or missed appointments, insurance claim updates, insurance and payment information, account registration or portal access, treatment-related notifications, and other messages related to care and services. Message frequency varies based on your interaction with Great Lakes Psychology Group services. Message and data rates may apply according to your mobile carrier plan.

Marketing & Promotional SMS/Text Messages (Optional)

As part of the Services, you may receive communications through the Services, including messages sent via email or SMS. By signing up for the Services and providing us with your wireless number, you confirm that you want Great Lakes Psychology Group to send you information that we think may be of interest to you. Great Lakes Psychology Group may use automated dialing technology to text you at the wireless number you provided, and you agree to receive communications from Great Lakes Psychology Group.

If you opt in to receive marketing messages, you also agree to receive automated promotional communications via text message from Great Lakes Psychology Group. These may include provider or service suggestions, newsletters and announcements, special offers, discounts, and other marketing communications. Message frequency varies. Message and data rates may apply. Reply STOP to any message to opt out at any time, or HELP for assistance. This consent applies only to messages from Great Lakes Psychology Group. You may also opt out of marketing emails by clicking “unsubscribe” in any message or by contacting support@glpg.net.

Opting out of marketing messages does not affect your ability to receive service-related or legally required communications.

Security Risks of Email and SMS/Text Messaging

Email and text messaging may travel over networks not controlled by Great Lakes Psychology Group, may be misaddressed or intercepted, and may be accessed improperly during transmission or storage. By agreeing to communicate via these channels, you acknowledge these risks and authorize Great Lakes Psychology Group to contact you by SMS text message and email despite these potential vulnerabilities.

You may decline to authorize the use of email and/or SMS/text messaging and still receive services from Great Lakes Psychology Group. If you prefer not to receive electronic communications, we will communicate with you by telephone or U.S. Mail.

When you call the office number (800-693-1916), or email support@glpg.net, you will reach our non-clinical office staff team. Due to your provider’s work schedule, they are often not immediately available by telephone. Generally, they will not answer the phone when they are in session. When unavailable, most providers route their calls to a personal voicemail that they monitor and your provider 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 unable to reach your provider and your situation is a non-emergency, you may contact the office by telephone or email. If you are unable to reach your provider and feel that your situation is life threatening, contact your family physician or the nearest emergency room. If your provider will be unavailable for an extended time, they should provide you with the name of a colleague to contact, if necessary.

All Members have the right to communicate complaints regarding their care. Should you wish to make a formal complaint about one of your care providers you may do so in writing and submit the concern to Great Lakes Psychology Group at support@glpg.net.

The laws and standards of the psychotherapy profession require that we keep Protected Health Information (PHI) about you in your Clinical Record. It includes information about your reasons for seeking therapy, a description of the ways in which your problem impacts on your life, your diagnosis, the goals that are set for treatment, your progress towards those goals, your medical and social history, your treatment history, any past treatment records that are received from other providers, reports of any professional consultations, your billing records, and any reports that have been sent to anyone, including reports to your insurance carrier. Except in the unusual circumstance that your provider concludes that disclosure could reasonably be expected to cause danger to the life or safety of you or another, or that disclosure could reasonably be expected to lead to your identification of the person who provided information to your provider in confidence under circumstances where confidentiality is appropriate, you may examine and/or receive a copy of your Clinical Record, and you must request this in writing. Because these are clinical records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we recommend that you initially review them in the presence of your provider, or have them forwarded to another mental health professional so you can discuss the contents. (In most situations, we are allowed to charge a $25.00 clerical fee, and a copying fee of $1.00 per page for the first 20 pages, $0.50 per page from pages 21-50 and $0.25 per page for pages 51+). If we refuse your request for access to your records, you have a right of review (except for information supplied to us confidentially by others), which your provider will discuss with you upon request.

HIPAA provides expanded rights regarding Protected Health Information (PHI). You can provide a written request to:

• Amend your Clinical Record.
• Request restrictions on what information in your Clinical Record is disclosed to others.
• Request an accounting of most disclosures of PHI and where they were sent.
• Request that any complaints you make about our policies and procedures be recorded in your record.
• Receive a printed copy of this Agreement and our privacy policies.

If you have questions about any of the contents of this Agreement, our procedures, or your role in this process, please contact us at support@glpg.net. Remember that the best way to ensure quality treatment is to keep communication open and direct with your provider(s).

By accepting this Agreement you indicate that you have read and understood this Agreement, and that you agree to abide by its terms. Further, you certify that if you accept this Agreement as a personal representative of the patient, you have legal authority to provide consent for the treatment of the patient. Your acknowledgement of this form indicates that you have read and understand this document and that you have had the opportunity to ask questions about anything in this form. By acknowledging this Informed Consent, you confirm and agree to the following:

• You have been informed and have had an opportunity to ask questions and receive answers about the potential risks, limitations, alternatives, and benefits of receiving services, whether in-person or through telehealth and, after considering such matters, you consent to receiving in-person services and telehealth services if such modality is appropriate and desired.
• No promises or guarantees have been made to me regarding the therapy services that you will receive.
• You have provided, or will provide before treatment, Great Lakes Psychology Group and your provider with accurate information regarding your identity and location.
• You have received information about the identity, practice location, and other information regarding your provider.
• You have been informed regarding how to enter appointments and communicate with your provider via Great Lakes Psychology Group’s telehealth platform, and will discuss a plan with your provider for how to work around technological difficulties and connections issues should they occur.
• If your provider determines that telehealth services are not appropriate for your condition or care, your provider may use other appropriate arrangements, including a referral or scheduling in-person services.
• You may refuse services at any time, without loss or withdrawal of treatment options or affecting your right to future treatment.
• You understand that Great Lakes Psychology Group does not provide psychiatric health care and that you will not be given a prescription at all.
• You understand that if you participate in a session, that you have the right to request a copy of your medical records which will be provided to you at reasonable cost of preparation, shipping and delivery.
• Our providers are an addition to, and not a replacement for, your primary care physician. Responsibility for your overall medical care should remain with your local primary care doctor, if you have one, and we strongly encourage you to locate one if you do not.
• All applicable confidentiality protections apply to our services, in accordance with Great Lakes Psychology Group’s Notice of Privacy Practices.