Please read and electronically sign the information below BEFORE you make an appointment.

Before completing this form, you MUST call your insurance company to confirm your benefits. An appointment may not be made if you have not done so.

Once you have read and signed the form below, you may print it for your records and press SUBMIT. Next, you may proceed to Step #2. Please print the "Release Form" and hand-write the information (Please bring this form with you to the first appointment). If there is no one you wish for Sherri Snyder-Roche, MA, LMHC to communicate with, you may skip Step #2 and move on to Step #3. Step#3 will ask for your health insurance information and then allow you to book your first appointment.

Thank you in advance. I look forward to meeting you.

Sherri

Under the laws of the United States and the state of Massachsetts your Personal Health Information (PHI) must be kept private. It is also required by law to give you this notice and to follow the terms of this notice while it is in effect. Changes in these privacy practices are allowed at any time as long as those changes are permitted or required by law. Any changes in these privacy practices will affect how the privacy of your PHI is protected, including any PHI received about you or created in the course of your therapy. These changes could also affect the protection of the privacy of any of your PHI received before the changes. If changes are made, a new notice will be available to you.

Your PHI will not be used or disclosed for any purpose not listed below, without your specific written authorization. You must give written authorization to disclose your health information to anyone for any reason you want. Any specific written authorization you provide may be revoked at any time by your written request.

 Health Care Provider - PHI may be used and disclosed to your physician or other healthcare provider who is also treating you.

 Payment - Your PHI may be used and disclosed to your health insurance plan or other third party for payment of services provided for you. If your contract with your insurance company requires that information relevant to the services provided be given before payment, providing them with a clinical diagnosis, as well as clinical information such as treatment plans or summaries and/or copies of any records maintained about your therapy sessions may be required.

 Health Care Operations - Your PHI may be used and disclosed the insurance company for the purpose of obtaining insurance eligibility, billing health insurance and inquiring about claim status.

 As Law Requires - Your PHI may be used and disclosed to any person required by federal, state, or local laws to have lawful access to your treatment program.

 Court Orders, Judicial and Administrative Proceedings, and Law Enforcement - Your PHI may be disclosed as part of a court proceeding, in response to a subpoena, or in other situations as required by law.

 Appointment Reminders - You may be contacted by phone or email for an appointment reminder. Other contact: If contact is by phone, a recorded message may be left on your voicemail unless you indicate otherwise.

 Therapist Cancellation – If for some reason an appointment must be cancelled, you will be contacted by phone or email. If contact is by phone, a recorded message may be left on your voicemail.

 Victims of Abuse, Neglect, or Domestic Violence - Your PHI may be used or disclosed to authorized persons from state agencies in cases of disclosures required by applicable state laws governing abuse, neglect, criminal activities, threats to the health/safety of the client and others, domestic violence, etc. In the case of minor children, the law requires such information to be disclosed.

 Event of an Emergency - Your PHI may be disclosed to a family member, a person responsible for your care, or your personal representative in the event of an emergency. If you are present in such a case, you will be given an opportunity to object. If you object or are not present or are incapable of responding, your PHI will be used or disclosed in your best interest at that time. In so doing, only the aspects of your PHI that are necessary for response to the emergency will be used or disclosed.

With limited exceptions, you can make a written request to inspect your PHI that is maintained in your mental health chart/record. Your PHI includes basic information about your diagnosis, treatment dates, treatment plans, intake, and payments made. Psychotherapy notes may be exempt from this ruling.

 Requested copies of any PHI information will be provided at the cost of $.25 per page plus charged $60/hour for time to completed the requested packets.

 You must make a written request to have your PHI communicated with you by alternative means at an alternative location. (An example would be if your primary language is not spoken and a child for whom you have lawful custody is being treated.) Your written request must specify the alternative means and location.

 You can make a written request that restrictions be placed on other ways we use or disclose your health information. Any or all of your requested restrictions may be denied. If these restrictions are agreed to, they will be abided by in all situations except those in which professional judgment constitutes an emergency.

 You can make a written request that your PHI be amended. If approved, your records will be changed accordingly. Notification will also be made to anyone else who may have received this information and anyone else of your choosing. If denied, you can place a written statement in your records disagreeing with the denial of your request.

Sherri Snyder, MA, LMHC is committed to ensuring that your privacy is protected.

Sherri Snyder, MA, LMHC will not intentionally share the contents of any email or information submitted via the internet with any third party. However, due to the nature of electronic communications, there is no assurance that the contents of your email will not become known or accessible to third parties. Although Sherri Snyder, MA, LMHC emails more quickly than phonecalls, please remember that there is no guarantee that email communicaion is completely secure. Should you choose to communicate via email, Sherri Snyder, MA, LMHC will respond to any emails sent until you request that form of communication to cease. Please take all precautions necessary to secure your email should you choose to use it for therapy communication. For a more secure manner of email communuication can be used via the TherapyAppointment.com website/link.

Please do NOT use email for emergencies or in the case of a crises.

As a mental health professional licensed by the State of Massachusetts through the Behavioral Sciences Regulatory Board (BSRB), I am committed to practice according to the ethics of my profession. You may contact the BSRB and/or the secretary of the United States Department of Health and Human Services with questions or to register complaints about any licensed mental health professional.

It is recommended that you print this

form and maintain it for your own records .

I called/contacted my health insurance company and verified my benefits. I give my permission for my therapist to use a copy of this authorization and my electronic signature to be used in place of an original signature for the use of insurance billing purposes.

I realize that I am personally responsible for the charges/fees not covered by the insurance.

I will notify my therapist if my health insurance changes.

I understand that I am required to provide at least 24 hours notice to cancel a scheduled appointment. If I forget my appointment, or cancel with less than 24 hours notice, I will be charged $60. This amount must be paid before or at the next session.

**(Please type your name below to indicate consent to treatment (for self or for my child/teen), comprehension of the above information, and to the above agreement.)**

If patient is a minor, the parent or guardian must sign below to consent to the minor receiving treatment.