Kim R. Tousignant, Psy.D
Psychotherapy Consultation Seminars Advocacy
Please read and/or fill out the forms below. Click on SUBMIT(where available) at the bottom of each form to send it to Dr. Tousignant.
* = REQUIRED Field
Instructions: The questions below ask about things that might have bothered you. For each question, SELECT from the drop-down box the answer that best describes how much (or how often) you have been bothered by each problem during the past TWO (2) WEEKS.
Answer Key:
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0- None Not at all |
1- Slight Rare, less than a day or two |
2- Mild Several days |
3-Moderate More than half the days |
4 -Severe Nearly every day |
VERY IMPORTANT PLEASE READ
IF YOU ARE COVERED BY MEDICARE
First, let me explain some of the important concepts.
Medicare is the federal insurance for folks who are retired or have disability benefits.
There is Part A: which covers hospitalizations.
There is Part B: which covers, doctors, testing, etc. This is the part of the policy that pays Psychologists.
There is Part D: Prescriptions. These are usually purchased separately from a private health insurance agency. For example AARP has a popular policy.
You can also purchase what is called a “Gap Policy”: This is purchased by you from a private health Insurance agency. It usually covers the co-pays for Parts A & B.
Medicare requires that you MUST allow payment to be made directly from Medicare to Kim Tousignant, Psy.D., a Clinical Psychologist. Medicare requires a special signature for that. The location for that is on my FORM below.
If you have MaineCare (that covers co-pays-which is different from MaineCare that pays only for your Part D plan) or a Gap policy, Medicare forwards the information, about what they pay, directly to tMaineCare/The Agency who then pays me the Co-Pays directly. Again, Medicare requires a special signature for me to bill them.
A NEWER option is a MEDICARE ADVANTAGE PLAN.
These are the plans advertised on TV, etc. They advertise you may be eligible for MORE services, such as dental, vision, money for pharmacies, and even the potential for rides.
YOU need to be VERY CAREFUL in learning about these programs.
HOW ADVANTAGE PLANS WORK:
If you buy these plans they take your federal Medicare coverage away from you. You can no longer use your Medicare card or number.
Then they develop their own private plans (through companies like Humana, Aetna, Blue Cross/Blue Shield-Anthem, etc.). You now use the Agency’s card.
A different MEDICARE ADVANTAGE program has some kind of DUO qualifier.
HOW ADVANTAGE DUO PLANS WORK:
If you buy these plans they take your federal Medicare coverage away from you AND your state Medicaid coverage (MaineCare) away from you. You can no longer use your Medicare card or number. You can no longer use your MaineCare card or number.
The Insurance Agencies develop their own private plans (through companies like Humana, Aetna, Blue Cross/Blue Shield-Anthem, etc.). You now use the Agency’s card.
LOTS OF PROBLEMS with ADVANTAGE and/or ADVANTAGE DUO plans.
Over the last 2 years I have had a number of clients get these plans. My clients have struggled to understand what they cover, or what the requirements for coverage are. Also clients seem to be told by the agent that it is “exactly like Medicare” or “nothing changes from Medicare”.
You need to fully understand the Advantage plans are NOT exactly like Medicare. Many things can change. I have made a table to try to help you understand these new programs.
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Issue |
Medicare |
MaineCare |
ADVANTAGE (DUO) |
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This table is specific to my practice as a Psychologist. The info is general and is not intended to be specific figures or plan. You must figure out exactly what the plan you intend to purchase covers. -each are separate. |
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Primary Care Provider -PCP |
Most providers take Medicare (not master level mental health clinician) |
Many providers take Maine Care |
You may need to change to their PCP. |
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Referrals [to see a specialist-i.e. Psychologist] |
Generally not needed for a Psychologist doing outpatient therapy. |
Generally not needed for a Psychologist doing outpatient therapy. |
Often Required from their providers to their specialists |
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Pre-Authorizations |
Generally not needed for a Psychologist doing outpatient therapy. |
Sometimes needed [Psychologists must get through online system] |
Often required with limits. |
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Co-pays |
Yes, about 20% [approx. $26 per session with this psychologist]. Can be covered by a GAP plan |
Just Mainecare: Small [such as $2-5 for psychologist]
Medicare +MaineCare co-pays are covered |
Some plans require you to pay co-pays that can be double or more than the Medicare regular co-pay. (i.e. $50). NOT able to be paid by GAP Plan. |
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Transportation |
No |
Yes-through an agency |
Maybe- BUT they use specific transportation agencies and some don’t have providers in Maine. |
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Kim Tousignant is on the panel and covered |
YES since 2013 |
YES since 2004 |
*Unlikely |
*Each and every Insurance agency that provides Advantage and Advantage Duo requires me (Dr. Kim) to sign up with them independently, even if I am already a provider for their regular insurance. This is labor and time intensive and can take up to 6 months for me to be approved. At this time I am not able to spare this time. So, if you want to see Dr. Kim Tousignant, you will need to confirm I am already in their plan.
Here is a recent example:
As noted above, I have been a Medicare provider since 2013, and a MaineCare provider since 2004. And an Anthem provider since 2004.
BUT…Anthem Advantage and Anthem Advantage Duo say I am NOT a provider for them.
[I spent almost 3 hours and 11 calls trying to figure out why they don’t have me as a provider. I was on hold multiple times and hung up on (we all know how these go). They finally gave me a provider liaison person’s name and number. The number was disconnected, therefore I am not going to be able to fix this to get on the panel.]
YOU MUST tell ME (Dr. Kim Tousignant) and all of your providers if you change from the Federal Medicare to a Private Advantage Program.
The insurances keep coming up with “creative ways” to save money and I am not able to investigate each plan or sign up for each Advantage Plan.
If you plan to change from your federal Medicare and/or MaineCare plan to an ADVANTAGE Plan with ANY insurance agency you must check out the following BEFORE getting an appointment with me.
- Is Dr. Kim Tousignant (NPI 1992870976) a provider for your specific plan?_____Yes _____No
- Do you need a new PCP to be on the new plan? _________Yes ______No
- Do you need a referral from your PCP to get psychologist services? _________Yes ______No
- Do you need pre-authorizations before seeing a Psychologist? _________Yes ______No
If YES: What is the process to get the pre-authorizations?_____________________________
___________________________________________________________________________
Provide all contacts info I need to get that preauthorization.______________________
___________________________________________________________________________
Make sure the numbers /addresses work. ___________________________________
Provide Dr. Kim with the form (s) needed to fill out. _________Yes ______No
I ,______________________ have read the prior 3 pages explaining Medicare, Gap plans and Advantage plans. I will immediately notify Dr. Kim if I EVER decide to change, in advance.
________________________________________________________ __________________
Client Signature Date
ONLY FILL OUT THE SECTIONS THAT APPLY TO YOU
__________________________________________________________________
SECTION 1
MEDICARE AUTHORIZATION (Federal)
I request that payment of authorized Medicare benefits be made on my behalf to Kim Tousignant, Psy.D. for any services furnished to me. I authorize holder of medical information about me to release to the Centers for Medicare & Medicaid Services (CMS) and its agents any information needed to determine these benefits or the benefits payable for related services.
Beneficiary Name___________________________
Medicare #___________________________ (NOT Social Security number)
___________________________________________Date_________________
(Beneficiary signature)
____________________________________________________________________________________
SECTION 2
MEDIGAP AUTHORIZATION (not MaineCare) MUST PROVIDE COPY OF CARD TO DR. KIM
I request that payment of authorized Medigap benefits be made on my behalf to Kim Tousignant, Psy.D., for any services furnished to me by this provider. I authorize any holder of medical information to release, to below identified name of Medigap Insurer, any information needed to determine these benefits or the benefits payable for related services.
Medigap Insurance Company________________________________________
Beneficiary Name___________________________________________________
Medigap Policy#_______________________________________
_____________________________________________Date_______________
(Beneficiary signature)
_____________________________________________________________________________________
SECTION 3
MAINECARE AUTHORIZATION
When you have Medicare + Mainecare copay coverage (not just Section D payment by MaineCare) Medicare is always the PRIMARY Insurer. MaineCare is always the SECONDARY provider. MaineCare will receive the information from Medicare about what Medicare paid. The left over deductibles, and co-pays Will be paid to Dr. Kim Tousignant by MaineCare. Therefore, I request that payment of authorized MaineCare benefits be made on my behalf to Kim Tousignant, Psy.D., for any services furnished to me by this provider. I authorize any holder of medical information to release to MaineCare any information needed to determine these benefits or the benefits payable for related services.
Beneficiary Name________________________________________
MAINECARE Policy Number_______________________________________
_____________________________________________Date_______________
(Beneficiary signature)
NOTICE OF PRIVACY PRACTICES
Effective Date:
THIS NOTICE DESCRIBES HOW MENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact Dr. Kim Tousignant.
WHO WILL FOLLOW THIS NOTICE.
This notice describes our practices and that of:
Any health care professional authorized by this agency to enter information into your chart.
Any member of a volunteer group we allow to help you working with Dr. Kim Tousignant.
All employees, staff and other personnel of Dr. Kim Tousignant.
All these entities, sites and locations follow the terms of this notice. In addition these entities, sites and locations may share mental health information with each other for treatment, payment, or Dr. Kim Tousignant’s operations and purposes described in this notice.
OUR PLEDGE REGARDING MENTAL HEALTH INFORMATION.
We understand that mental health information about you and your health is personal. We are committed to protecting mental health information about you. We create a record of the care and services you receive with Dr. Kim Tousignant. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by Dr. Kim Tousignant. Other Health Care Rehabilitation Facilities may have different policies or notices regarding use and disclosure of you mental health information.
This notice will tell you about the ways in which we may use and disclose mental health information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of mental health information.
We are required by law to:
Make sure that mental health information that identifies you is kept private;
Give you this notice of our legal duties and privacy practices with respect to mental health information about you; and
Follow the terms of the notice that is currently in effect.
Generally, information will only be released with your express permission to release. We can not talk to anyone or share your information with anyone without your express written permission, and you have the right to withdraw your permission at any time.
HOW WE ARE REQUIRED BY LAW TO DISCLOSE MENTAL HEALTH INFORMATION ABOUT YOU.
As Required By Law. We will disclose mental health information about you when required to do so by federal, state, or local law.
Health Oversight Activities. We will disclose mental health information as required by law to health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
To Avert a Serious Threat to Health or Safety We will disclose mental/medical health information about you when we have a “Duty to Report” under state or federal law, because we believe that it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Public Health Risks We will disclose mental / medical health information about you for public health reporting required by federal or state law. These activities generally include the following:
To prevent or control disease, injury or disability;
To report child abuse or neglect;
To report suicidal or homicidal situations;
To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
To notify the appropriate government authority if we believe a client has been the victim of abuse, neglect, or domestic violence. We will only make this disclosure if you agree or when required by law.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we will disclose mental health information about you when properly ordered to do so by a court under certain circumstances. Your permission is generally required for Dr. Kim Tousignant to release information to a court or regulatory board if a formal complaint is filed or in defense of legal action. Each board generally has guidelines to de-identify client records in these situations, and these guidelines will be followed.
Law Enforcement. We will release mental health information if required to by specific law enforcement officials, i.e. judges, and if permitted by state and federal law.
HOW WE MAY USE AND DISCLOSE MENTAL HEALTH INFORMATION ABOUT YOU.
The following categories describe different ways that we use and disclose mental health information. For each category of uses or disclosures we will explain what we mean and try to give some examples. Not every uses or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
For Treatment. We may use mental health information about you to provide you with mental health treatment or services. We may disclose mental health information about you to doctors, psychologists, nurses, social workers, therapists, technicians, medical students, or other in-house personnel who are involved in assisting/treating you. Different departments may share mental health information about you in order to coordinate the different things you need and making sure you receive professional and competent services. At times we may seek outside consultation from professionals. Either clients sign a release allowing the sharing of information or every attempt is made to remove any identifying information or every attempt is made to remove any identifying information such as name, family members, age, etc. With a release of information, we also may disclose mental health information about you to people outside Dr. Kim Tousignant, such as other health care providers involved in providing mental health treatment for you and to people who may be involved in your mental health care, such as family members, clergy or others we use to provide services that are part of your care.
For Payment. We may use and disclose mental health information about you so that the treatment and services you receive with DR. KIM TOUSIGNANT, or other health care providers from whom you receive treatment, may be billed to, and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about treatment you receive with DR. KIM TOUSIGNANT so your health plan will pay or reimburse you for your treatment. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
For Health Care Operations. We may use and disclose medical information about you for operations or to another health care provider or health plan, if you have a relationship with that health care provider or health plan. These uses and disclosures are necessary to operate this practice and make sure that all of our clients receive quality care. For example, we may use mental health information to review our treatment and services and to evaluate the performance of our staff in providing services for you. We may also combine mental health information about many clients to decide what additional services this practice should offer, what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, social workers, therapists, nurses, psychologists, technicians, interns, and other personnel for review and learning purposes. We may also combine the mental health information we have with mental health information from other Health Care Providers to compare how we are doing and see where we can make improvements in the care and service we offer. We may remove information that identifies you from this set of mental health information so others may use it to study health care and health care delivery without identifying the names of specific clients. In order to maintain licensure and accreditation of the agency, periodic reviews of client files may need to be made by quality assurance professionals, spot reviewers, MaineCare reviewers, licensure and accreditation reviewers. They will be bound by state and federal confidentiality regulations.
Appointment Information. With your written permission we may use and disclose medical information to contact you about an appointment for treatment or medical care with DR. KIM TOUSIGNANT
Individuals Involved in Your Care or Payment for Your Care. We may release certain limited information about you to a friend, family member, or others (emergency contact) who are involved in your medical care with a release of information. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.
SPECIAL SITUATIONS
Military and Veterans. If you are a member or the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority.
Coroners, Medical Examiners and Funeral Directors. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about clients of DR. KIM TOUSIGNANT to funeral directors as necessary to carry out their duties.
Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.
CHANGES TO THIS NOTICE
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in each of our facilities. The notice will contain on the first page, in the top right hand corner, the effective date. In addition, each time you register at or are admitted with DR. KIM TOUSIGNANT for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with DR. KIM TOUSIGNANT or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.
You can also submit a complaint to the United States Department of Health and Human Services. Send your complaint to:
Office for Civil Rights
Room 509F,
OCR Hotlines – Voice: 1-800-368-1019
We will never retaliate against you for filing a complaint.
OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
CANCELLATION POLICY
(Revised 6/1/15)
Dear Clients,
I consider your time very valuable. When I make an appointment with you, I arrange my schedule so that I will be in the office to meet specifically with you and no one else. Since psychotherapy sessions are 45 minutes long, unlike physicians, we do not have the luxury of “double booking” and “fitting people into the schedule” when someone does not show up. This policy is designed to clarify any confusion and be clear about my No Show Policy. This Policy is intended to be flexible, as I want to be understanding when an emergency arises, so I will also highlight what I consider an emergency.
Types of Cancellations
A No Show happens when someone does not show up for a scheduled appointment. This means that I sit at my office and wait for you to arrive, as I assume you may be running late.
My Policy: There will almost always be a fee for missing
an appointment in this manner.
A Brief Notice Cancellation happens when someone calls to cancel a scheduled appointment less than 24 hours in advance of that appointment.
My Policy: There will most likely be a fee for missing an
appointment in this manner.
A Cancellation is when someone calls at least 24 hours or more in advance to cancel an appointment.
My Policy: There will never be any charge for this form of
cancellation. (Unless you are participating in court-mandated treatment - then refer to that separate policy).
Situations
Situations that I consider emergencies include things like- being in the hospital, being in a car accident, being the victim of some type of crime that day, your car unexpectedly dies, you are very sick or you have a very sick child, blizzards, etc.
My Policy: depending on the situation, I probably won’t
charge you if there is a No Show or Brief Notice
Cancellation.
Situations which are not emergencies are the types of things that can be scheduled around this appointment or where you can call to give me advance notice and we can discuss options- for example, another doctor’s appointment, you need to visit a friend, you need to pay bills, your car has been broken down for a week, you want to sleep in, you are “too busy,” forgetting to put it on the calendar, etc.
My Policy: I will charge you for a No Show. I may charge you for a Brief Notice Cancellation. We will discuss the situation and I will consider your reasoning when you disagree with my decision.
Cancellation Fees
I have a progressive fee schedule that depends on a number of factors.
If you are mandated into treatment, there will be NO DISCOUNTS on Cancellation fees. You will owe the FULL FEE of $140 per session (45 minutes) if you miss for a No Show, or a Brief Notice Cancellation and even a non-approved cancellation. The fee must be paid in full prior to my seeing you again.
If you self-pay or have insurance other than MaineCare, then the Fee for No Show or Brief Notice Cancellation is ½ of the agreed upon session amount (with you or your insurance company) for the first 3 of these in a year. For the rest of the year the charge for No Show/ Brief Notice Cancellation will be the full session amount. Generally this fee is due at the time of our next session.
I am not allowed to bill for MaineCare No Shows. I want to continue to be able to provide services to clients who have MaineCare, however after 3 missed appointments we will need to discuss whether this is the right time for you to be in treatment.
STANDING APPOINTMENT TIMES
I often provide clients with “Standing Appointment Times.” This means that you have a time you see me every week, or every other week, or maybe once a month. This is advantageous because it reduces forgetting and helps you plan other things around our appointment time. When someone misses their Standing Appointment Time with a No Show I am often left wondering about whether you plan on being at your next Standing Appointment Time. Therefore, if you No Show, you need to assume you no longer have that Standing Appointment Time. I MUST hear from you if you want to keep your Standing Appointment Time, especially during prime times (i.e., 2pm, 3pm or 4 pm.).
If you have any questions, comments or concerns, please talk with me about them. Please feel free to leave detailed appointment information on voicemail or in texts.
Thank You
NOTIFICATION OF RIGHTS / CONSENT TO BEGIN TREATMENT (rev. 4/15/20)
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Client Name: |
DOB |
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Interpreter Needed ( ) No ( ) Yes Reason Interpreter needed:
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Interpreter Signature |
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A Legal Guardian or Representative was ( ) chosen ( ) not chosen by client |
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If chosen the following person is designated as Legal Guardian or Parent or Personal Representative: Name Address:
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DOCUMENTS: |
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Completed |
Signed |
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NOTIFICATION OF RIGHTS/CONSENT TO BEGIN TREATMENT |
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CLIENT INFORMATION SHEET |
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PERMISSION TO CONTACT YOU |
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PERMISSION TO BILL |
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IN1 |
AUTHORIZATION FOR MEDICARE |
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DISCLOSURE STATEMENT ( ) ADULT ( ) CHILD |
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TELEHEALTH AUTHORIZATION |
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PT1 |
SUMMARY OF RIGHTS FOR RECIPIENTS OF OUTPATIENT SERVICES |
KEEP |
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NOTICE OF PRIVACY PRACTICES |
KEEP |
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PT3 |
CANCELLATION POLICY |
KEEP |
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PT4 |
PRICE LIST |
KEEP |
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R1 |
AUTHORIZATION FOR RELEASE OF INFORMATION |
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COMPREHENSIVE ASSESSMENT FOR CLIENT COMPLETION |
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CA ADDENDUM: MENTAL STATUS EXAM ( ) CHILDHOOD ( ) ADULT |
I do this |
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MaineCare Folks: AC-OK ( ) ADOLESCENT ( ) ADULT |
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DSM-5 SELF-RATED LEVEL 1 CROSS-CUTTING SYMPTOM MEASURE ( ) 6-17 ( ) 11-17 ( ) ADULT |
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On this date I have been made aware of my State of Maine and Federal rights as a Consumer of Mental Health Services. I have received a copy of the documents checked under the ’Received’ column on Page 1. I have had a chance to ask further questions about any of the documents I have been shown. I have been instructed as to where and how I may obtain paper copies or electronic copies of Maine’s Rights of Recipients of Outpatient Mental Health Services.
I now voluntarily agree to and consent for Mental Health Services through Dr. Kim Tousignant:
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Client Signature |
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Signature of Authorized Person Basis for Authorization (Relationship to Client) |
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Please do not write below this line.
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I agree that I have gone over the checked items on Page 1 with the client. I believe the client (and/or) their legal guardian/representative has the capacity to give informed consent to treatment. |
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I agree that I have gone over the checked items on Page 1 with the client. I believe the client (and/or) their legal guardian/representative did not have the capacity to understand the information completely and I made these special accommodations:
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Kim Tousignant, Psy.D |
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AUTHORIZATION CLIENT NAME:_________________________________________________
FOR RELEASING/OBTAINING DATE OF BIRTH:________________________________________________
Mental Health Information and/or Disability Related Information CLIENT #:______________
Dr. Tousignant intends to strongly protect any information, communication and records received in the course of treatment. Dr. Tousignant commits to helping you understand if release of your information may be helpful or cause unexpected outcomes, to the best of her ability, even though all possible outcomes are impossible to predict.
I,___________________________________ agree to allow Dr. Kim Tousignant, [PO Box 1694, Bucksport, ME 04416; Phone: (207) 944-8881; FAX:(207) 469-1932] to:
RELEASE TO: OBTAIN FROM: Written &/or Electronic (internet, email, text) &/or Verbal
Name of Organization /Person______________________________________________________________________________________________
Street Address________________________________________________________________ Phone (if available)____________________________
City, Zip _____________________________________________________________________FAX(if available)_______________________________
Website:____________________________________Email:_______________________________Other:__________________________________
I understand that I have the right to:
- Obtain a copy of this authorization, and to review and copy any information prior to it being released.
- Review my records and refuse authorization to disclose all or some of the information.
- Revoke this authorization by written notice to the health care provider at any time, except where the health care provider has already acted upon the authorization. (See exception to this Right in the Notice of Privacy Practices in the Client Handbook given to you at intake).
I understand that such refusal or revocation may result in improper diagnosis or treatment, denial of program admission, denial of insurance coverage or a claim for health benefits or other adverse consequences. I further understand that information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient. In the event the information is further disclosed by the receiving party, it may not be protected under federal privacy regulations. Such information may not be redisclosed by Dr. Tousignant without my specific written consent.
The purpose of this release is to : ______________________________________________________________________________
The extent and nature of information to be released or obtained includes:
Clinical Intake/Diagnosis Progress Notes Final Discharge Summary
Psychiatric Evaluation Treatment Plan/Plan of Care Other: _______________________________
This authorization for releasing/obtaining information is to be in effect through _______________(date) unless otherwise revoked.
_________I understand that email & the internet may not be secure forms of information transmission, as there are risks Dr. Tousignant cannot control; information may be read by a third party. I agree to accept those risks & allow Dr. Tousignant to send my information in electronic format if needed.
I understand that my health care provider(s) need my specific consent to disclose information related to any of the following. (please initial)
____1. Substance/Alcohol/Drug Use &/or Abuse Treatment: I ( DO or DO NOT ) authorize disclosure of information which refers to any treatment
or diagnosis of substance and or drug or alcohol use &/or abuse.
____2. Mental Health Records: I ( DO or DO NOT ) authorize disclosure of information which refers to treatment or diagnosis of mental health by a
provider or program
____3. HIV Records: I ( DO or DO NOT )authorize disclosure of information which refers to HIV test results, infection status, or treatment information. This information may have unexpected implications which could be positive or negative to you, and may result in discrimination if the data is misused.
____4. Other Vocational-Medical: I( DO or DO NOT ) authorize disclosure of information which refers to vocational – medical information.
____5. Prior Review : I ( DO or DO NOT )want to review such information before it is released. I understand that such reviews must be supervised.
I am signing this form voluntarily , and wish the information to be released in order to serve my best interest:
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Client Signature Date
________________________________________________________________ ________________________ ______________
Signature of Authorized Person Basis for Authorization (Relationship to Client) Date
___________________________________________________________________________ ____________
Witness Date
REVOCATION: I hereby revoke this Authorization for the releasing/obtaining of information. I fully understand this does not apply to information that has already been released.
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Client Signature Date
_____________________________________________________ _______________________________________ ______________
Signature of Authorized Person Basis for Authorization (Relationship to Client Date (REVISED 2/26/16)
Page 1 of 2
Doxy.me is my chosen Video-Conferencing site. Internet address to type in: https://doxy.me/drkimt
You DO NOT NEED a free-standing application for this new Videoconferencing site. It works with FireFox or Chrome. On your Android phone use Google Chrome.
Here is a You Tube Video showing how to use it. https://youtu.be/yJf9N9sjDLI
Dr. Kim Tousignant is offering Video-Conferencing services to active clients who reside in the State of Maine, where I am licensed as a Psychologist. There may be potential benefits and risks of Video-Conferencing (e.g. limits to patient confidentiality) that differ from in-person sessions. The following guidelines and limitations are designed to increase client safety on both ends of the conferencing.
DR. KIM’S RESPONSIBILITIES:
♦ Your confidentiality remains one of Dr. Kim’s utmost concerns.
♦ Doxy.me is a Video-conferencing site designed for health professionals that has state-of-the-art-encryption that meets HIPAA
requirements. Even so, anything based on the internet has the potential to not be a secure form of information transmission, as there may be risks Dr. Kim cannot control.
♦ Dr. Kim will provide assistance in the use of this application to the best of her ability.
♦ Dr. Kim agrees to use only personal Wi-Fi and will not use public Wi-Fi sites. She will use a computer or smartphone.
♦ Dr. Kim agrees to have a quiet, confidential space to conduct TelePsychology, preventing any other person to be within an area to
hear our session. Should any concern arise Dr. Kim or the client will have the right to exclude anyone from either site.
♦ Your status as an open client to Dr. Kim will never be predicated upon use, or lack of use, of Telehealth services.
♦ As with in-office sessions, no session will be recorded by Dr. Kim without your express signed authorization.
♦ Dr. Kim will continue to document sessions and retain records, via the usual means, as required by State and Federal laws, in
writing. In addition, Dr. Kim is required to notate that services were conducted via TeleHealth, the location of the provider and the location of the client, and any interferences that occur.
♦ If clients do not have the capabilities required for Telehealth but desire Video-Conferencing, Dr. Kim agrees to assist clients in
accessing nearby locations with video-conferencing services.
♦ Dr. Kim agrees to continually assess whether the Video-Conferencing method of providing services continues to meet a client’s
needs for psychotherapy services. She may, at any time, determine, due to circumstances, in-person sessions will be required. Dr. Kim agrees to discuss these issues as they arise, and when possible consult with client during decision-making.
♦ Dr. Kim agrees to develop a back-up-plan, with the client, in the event of technical difficulties or crisis situations. This may include:
an active phone number to restart or finish the session; An emergency contact and clarification of the closest Emergency Room; access to Crisis Services, etc.
♦ If a client is under age 18 Dr. Kim agrees to have Parent(s) written permission for Video-Conferencing to occur, as laws require.
♦ Dr. Kim must obtain your physical location and an alternative emergency phone number in case of emergency (say you have a medical emergency) at the beginning of every session.
CLIENT RIGHTS: I, _________________________________________(name) understand I have the right to:
♦ Request limitations, accommodations, even stop any session that has begun, if I so desire. I can also refuse services via
Telehealth, requesting they be in-office only. However, there may be limitations to Dr. Kim’s ability to provide timely service based upon Town, State and Federal guidelines, i.e. if Dr. Kim or I become quarantined due to health concerns, etc.
♦ Obtain a copy of this authorization, and to review and copy any information.
♦ Review my records, as is afforded in my usual State and Federal Rights.
♦ MaineCare clients have the right to get transportation (per MaineCare guidelines) to a facility where they can access Telehealth, if
they desire.
♦ Revoke this authorization by written notice to the health care provider at any time, except where the health care provider has
already acted upon the authorization. (See exception to this Right in the Notice of Privacy Practices in the client materials and links given to you at intake).
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CLIENT RESPONSIBILITIES: I, __________________________________(name), agree to review these carefully.
♦ A scheduled TeleHealth Appointment shall be considered the same as an in-person session in regards to scheduling. It is important to be available at the scheduled time. I agree to notify Dr. Kim in ADVANCE, by phone, email, text or other messaging program we have agreed to use, should you need to cancel an appointment. There may be cancellation and/or No Show fees, as allowed by your insurance.
♦ I understand that participation in Telehealth services with Dr. Kim is completely voluntary.
♦ To access TelePsychology from home I will need to use a computer with webcam, laptop with webcam, or smart phone.
Alternatively, I may be able to travel a short distance to a designated location.
♦ I agree to have a quiet, confidential space where I can participate in the Video-Conferencing. I agree to disclose any other person
that may be within an area to be able to hear our session. PLEASE NOTE: If you have a server such as Google Home, Google Nest, Alexa, Suri, Echo,etc. are constantly listening and some may be recording. It is recommended these be turned off if you think they can hear you in a room. Should any concern arise I understand either I or Dr. Kim have the right to exclude anyone from either site.
♦ I agree to confirm with my insurance company that they will reimburse for TeleHealth Services. If any pre-authorizations are
needed I must alert Dr. Kim in ADVANCE. If they are not reimbursed, I am responsible for full payment as agreed in the authorization to bill document.
♦ Should I feel the desire to record sessions, Dr. Kim requires I let her know in advance so she can sign confirmation to that effect.
♦ I agree to discuss my opinions and concerns about the Video-Conferencing method if it is uncomfortable or interferes in my receipt
of psychotherapy.
♦ I agree to work with Dr. Kim to develop a back-up-plan in the event of technical difficulties or crisis situations. This may include:
an active phone number to restart or finish the session; An emergency contact and clarification of the closest Emergency Room; access to Crisis Services, etc.
This authorization for TELEHEALTH Services is to be in effect through ______________________(date) unless otherwise revoked.
As with all psychotherapeutic services, results may be helpful or cause unexpected outcomes and all possible outcomes are impossible to predict.
I agree to accept the risks and responsibilities noted above and voluntarily request and allow Dr. Kim to interact with myself utilizing TELEHEALTH services in order to serve my best interest:
_____________________________________________________ ___________________________
Client Signature Date
________________________________________________________________ ________________________ ______________
Signature of Authorized Person Basis for Authorization (Relationship to Client) Date
___________________________________________________________________________ ____________
Witness Date
REVOCATION: I hereby revoke this Authorization for TELEHEALTH Services. I fully understand this does not apply to information that has already been released.
___________________________________________________________________________ ______________
Client Signature Date
_____________________________________________________ _______________________________________ ______________
Signature of Authorized Person Basis for Authorization (Relationship to Client ) Date (REVISED 3/17/2020)
Dr. Kim Tousignant (“Dr. Kim”)
PERMISSION TO BILL (rev. 1/29/25)
CLIENT NAME DATE OF BIRTH CLIENT #
IMPORTANT BILLING INFORMATION!
PLEASE MAKE SURE YOU READ IT
It is very important that you understand the following:
- By making an appointment (generally for 1 hour) with Dr. Kim you understand that she will bill a minimum of 30 minutes. An appointment means you have agreed to pay for the time Dr. Kim has set aside specifically and only for YOU.
- Your billing INFORMATION MUST BE UPDATED YEARLY OR ANY TIME YOU CHANGE INSURANCES. Insurance companies have strict filing guidelines often within 60-90 days. YOU ALONE are responsible for giving me the accurate information the day of any insurance policy changes. If you do not give me the accurate information, you are responsible for ALL of those session fees, immediately. (These are not your insurance’s allowed amounts, it is my full fee (see price list.). This is also true if you change your name and do not give me the date of change.
- You are responsible for figuring out any pre authorizations that your insurance may require of me, and to notify me immediately of those.
- Each insurance company is DIFFERENT and they are not easy to deal with. My submitting claims to your insurance is a courtesy to you (But costs me a lot). You are responsible for the bill and all calculations such as copays, co-insurance & deductibles over the entire course of your treatment. If there are complications with your insurance Dr. Kim may decide you will be require to pay full fee at time of service. Then Dr. Kim will give you what is called a “super bill” so you can submit it to your insurance directly. If you prefer, we can do this from the start.
- No Shows and late cancellations (see policy document) are not paid for by your insurance company. Dr. Kim charges a fee for them when allowed by your insurance. The minimum fee you will be required to pay is $100. Some insurances do NOT allow a charge for this. Therefore, with insurances like Mainecare, if there are 3 no shows or late cancels (throughout treatment) Dr. Kim has the right to stop providing the service (without any legal (State or Federal) repercussions).
- You agree you are responsible for ANY portion of the bill that your insurance company does not cover (except when my contract with your insurance company specifies Dr. Kim cannot balance bill.)
- Federal Law requires I collect copays, co-insurances or pay downs. This includes the $2 fee for adults on Mainecare and the yearly (January usually) Medicare deductible. Please make sure you have that when you come into session.
- EXTRA SERVICES are not covered by any insurance: requesting documents, or specialized services as in testifying, specialty meeting attendance, disability assessments or Family Leave Forms, writing support or special letters, etc. My normal fee for this is $350 an hour.
- Once a balance becomes 6 months old, Dr. Kim has the right to seek legal actions to collect the debt, as in a collection agency, reporting to your credit bureau and/or potential tax repercussions to you.
By signing this document you are giving formal permission to allow Dr. Kim to bill your insurance for out-patient psychotherapy, assessment and/or consultation services (as allowed by the insurance). You also allow Dr. Kim Tousignant to receive payment directly from your insurance company.
Guarantor: Name, address and SS# (if different than client)
You are responsible for telling me if a Referral is Needed? N Y
You are responsible for telling me if a Preauthorization is Required? N Y
SECONDARY Insurance Company_
# Member # Group
Guarantor: Name, address and SS# (if different than client)
You are responsible for telling me if a Referral is Needed? N Y
You are responsible for telling me if a Preauthorization is Required? N Y
Client Signature ________________________________ Date
Signature of Authorized Person___________________________ Date