No show/cancellation policy: 

Consistency is an important part of your or your child's therapy. We also hold appointment times for you and your family that we cannot offer to other families if an appointment is canceled at the last minute. For no shows or cancellations made less than 24 hours in advance, a late cancel/no-show fee of $50 will be charged to your card on file. We may choose to waive the fee at our discretion. 

Because we understand that sometimes people make mistakes or circumstances are beyond your control, our general guideline is to waive the fee for the first no-show/cancellation and for unforeseen or emergency circumstances such as sudden illness and dangerous road conditions. Please note that if frequent cancellations and no-shows are interfering with treatment, your therapist may need to terminate treatment or no longer guarantee a certain time slot in order to offer this time to another client. 

Clients using Medicaid insurance are exempt from the late cancel/no show fee, but your therapist may not be able to guarantee a regular time slot for treatment in the case of recurring no shows or cancellations. 

Insurance Policy: 

By entering your insurance information, you are giving us permission to bill your insurance and to communicate the personal information with your insurance company necessary for billing purposes. Please note that we must provide a mental health diagnosis in order to bill insurance. Please discuss this with your or your child's therapist if you have concerns about this diagnosis. We believe that, while a diagnosis may be necessary, it is merely a description of symptoms and does not define you or your child.  

Please be advised if you are using insurance coverage, this is a contract between you and your insurance company, not Family Roots Therapy.

We will verify your insurance benefits prior to treatment as a courtesy to you. We do our best to provide accurate information about your insurance benefits, but please note that we can only provide an estimate of the cost of services. You are ultimately responsible for understanding your insurance benefits and you will be responsible for any fees not covered by insurance. If you are concerned about coverage, we encourage you to contact your insurance company directly to confirm coverage. 

You are also responsible for keeping your insurance information updated and notifying us of any changes in coverage. 

Please choose the "self pay" option if you are paying out of pocket for services. If you require a superbill to be reimbursed by your insurance company, please let us know by contacting info@familyrootstherapy or 503-746-3373 and we will provide instructions for how to download your superbills/receipts from the client portal. 

Credit Card on file: 

We require that all clients save a credit card on file. You will be prompted to enter credit card information when filling out paperwork. Your credit card information is stored securely in our client portal. We cannot even see the credit card information once you enter it. 

By accepting this policy, you are consenting to charge any unpaid balances and cancellation fees as described in our policies to the card on file. 

Most clients prefer to have us bill the co-pay or session rate each week as a courtesy rather than log in to pay an invoice each week. If you prefer to pay each invoice on your own rather than be billed automatically, please let us know (info@familyrootstherapy.com) and we will not automatically bill your card each week. 

Please note that we do not allow clients to carry a balance (unless you have arranged for a payment plan) and your payment will be due each week at the time of session. Please note that if you choose not to be billed automatically, you may still be charged for overdue balances and cancellation fees. We will make attempts to reach out to you to arrange payment prior to making these charges. 

Due to current circumstances of offering virtual appointments only, we do not accept cash or checks as forms of payment at this time. 

Because we are mindful of our clients' privacy, Family Roots offers secure messaging through our client portal. If you wish to communicate electronically about your treatment or your child's treatment, the client portal is the most secure method. 

Your therapist may use e-mail to communicate about scheduling needs but will not send sensitive or personal information via unencrypted e-mail. You may choose to use unencrypted e-mail to communicate with your therapist if you prefer, as we recognize that some clients prefer e-mail communication. 

Please do not use text messages (SMS) to communicate with your therapist, as our phone system does not allow for texting on each therapists' individual extension. 

Family Roots uses Google Meet for Telehealth video sessions, which is a HIPAA secure video platform. You will receive links to join these sessions via e-mail. 

Therapists at Family Roots will not use any form of social media to communicate with clients and will not engage with clients on social media in any way, even if a client initiates contact. 

By signing below, I acknowledge that I have been informed of the risks of electronic communication and accept these risks should I choose to use unencrypted forms of communication. 

Family Roots Therapy providers who feel comfortable offering in-person sessions will follow all CDC and state guidelines for preventing the spread of illness. This includes physical distancing, wearing a mask, hand washing, and sanitizing. Guidelines will be shared with clients and providers will ask clients to adhere to all guidelines as well. 

Clients who cannot or will not adhere to guidelines for physical distancing and mask-wearing will be offered telehealth sessions rather than in-office sessions. 

Please do not attend an in-person session if you or someone in your household: 

-Has symptoms of COVID-19 (fever, chills, cough, shortness of breath, fatigue, headache, sudden loss of taste or smell)

-Has a fever of 100.4 degrees fahrenheit or higher

-Is undergoing evaluation for COVID-19 (such as a pending viral test)

-Received a diagnosis of COVID-19 (SARS-CoV-2) infection within the last ten days

-Has had close contact to someone with COVID-19 (SARS-CoV-2) infection within the last 14 days

If you are experiencing any signs of illness, please let your provider know as soon as possible and a telehealth session will be offered instead.

Notification of Fees:

Insurance:

Family Roots Therapy is contracted In-Network with various insurance companies and may be able to bill your insurance for part or all of your fees.  Clients using insurance out of network must pay the full prices listed above and are NOT eligible for sliding-scale. If we are in network with your insurance company, you are responsible for paying the patient responsibility according to your explanation of benefits (EOB) from your insurance, including co-pays, co-insurance or paying toward your deductible. You are ultimately responsible for knowing these details of your insurance coverage and for providing us with up to date insurance information. You must notify our office of any insurance changes or terminations. We provide an estimate of your costs as a courtesy, but please note that our estimate is an estimate only and not a guarantee of what your final bill will be. Please check with your insurance company directly to understand what services are covered. The explanation of benefits (EOB) that you receive from your insurance company will determine your patient responsibility. EOBs are typically processed and sent about 3-4 weeks after your session is billed. 

Please inquire about the following billing codes depending on your needs:

90791 - Mental Health Assessment (60 minutes)

90837 - Individual session (53+ minutes)

90834 - Individual Session (45 minutes)

90847 - Couples/Family Session (60 minutes)

90846 - Parent/Spouse support session w/o client present (60 minutes)

Payment of Fees:
Payment of fees you are responsible for is due upon the date of service.  Your counselor may choose to reschedule your appointment if you are unable to pay for the service. If you have a balance on your account, you will receive a statement. All accounts are due and payable within 14-days of notification. If you have questions regarding the payment of fees, please discuss them with our office manager or your counselor. Please discuss any concerns you may have regarding payment BEFORE it becomes delinquent.

If a client fails to be responsible for the account, and it is necessary to place a delinquent account into the hands of a collection agency/attorney, the client agrees to pay all court costs affixed by the court.

Your counselor accepts credit cards (Visa/MC, American Express, Health Accounts). These payments can be made on our client portal. 

Unpaid balances will be automatically charged to the card on file at the end of the week (Friday) if a copay or session fee was not paid at the time of service as outlined in our credit card agreement.

We are unable to accept checks at this time. 

Opportunity to Register to Vote in Oregon

At Family Roots Therapy we believe everyone should have the opportunity to vote in the state they reside and are receiving services in. We provide access to voter registration forms at our lobby entrance. 

Signing this form states that you have received notification of access to voter registration forms and understand that you may register to vote at any time.

Client Bill of Rights

Clients of counseling or therapy services offered by Oregon licensees have the right:

  To expect that a licensee has met the minimum qualifications of training and experience required by state law;

  To examine public records maintained by the Board and to have the Board confirm credentials of a licensee;

  To obtain a copy of the Code of Ethics;

  To report complaints to the Board;

  To be informed of the cost of professional services before receiving the services;

  To be assured of privacy and confidentiality while receiving services as defined by rule or law, including the following exceptions:

o   Reporting suspected child abuse;

o   Reporting imminent danger to the client or others;

o   Reporting information required in court proceedings or by client's insurance company or other relevant agencies;

o   Providing information concerning licensee case consultation or supervision; and

o   Defending claims brought by the client against licensee;

  To be free from being the object of discrimination on any basis including age, color, culture, disability, ethnicity, national origin, gender, race, religion, sexual orientation, marital status, or socioeconomic status while receiving services.

In addition to all applicable statutory and constitutional rights, every individual receiving services has the right to:

  Choose from services and supports that are consistent with the assessment and service plan, culturally competent, provided in the most integrated setting in the community and under conditions that are least restrictive to the individual's liberty, that are least intrusive to the individual, and that provide for the greatest degree of independence;

  Be treated with dignity and respect;

  Participate in the development of a written Service Plan, receive services consistent with that plan and participate in periodic review and reassessment of service and support needs, assist in the development of the plan, and to receive a copy of the written Service Plan;

  Have all services explained, including expected outcomes and possible risks;

  Confidentiality, and the right to consent to disclosure in accordance with ORS 107.154, 179.505, 179.507, 192.515, 192.507, 42 CFR Part 2 and 45 CFR Part 205.50.

  Give informed consent in writing prior to the start of services, except in a medical emergency or as otherwise permitted by law. Minor children may give informed consent to services in the following circumstances:

o   Under age 18 and lawfully married;

o   Age 16 or older and legally emancipated by the court; or

o   Age 14 or older for outpatient services only. For purposes of informed consent, outpatient service does not include service provided in residential programs or in day or partial hospitalization programs;

  Inspect their Service Record in accordance with ORS 179.505;

  Refuse participation in experimentation;

  Receive medication specific to the individual's diagnosed clinical needs including medications used to treat opioid dependence;

  Receive prior notice of transfer, unless the circumstances necessitating transfer pose a threat to health and safety;

  Be free from abuse or neglect and to report any incident of abuse or neglect without being subject to retaliation;

  Have religious freedom;

  Be free from seclusion and restraint;

  Be informed at the start of services, and periodically thereafter, of the rights guaranteed by this rule;

  Be informed of the policies and procedures, service agreements and fees applicable to the services provided, and to have a custodial parent, guardian, or representative, assist with understanding any information presented;

  Have family and guardian involvement in service planning and delivery;

  Make a declaration for mental health treatment, when legally an adult;

  File grievances, including appealing decisions resulting from the grievance;

  Exercise all rights set forth in ORS 109.610 through 109.697 if the individual is a child, as defined by these rules;

  Exercise all rights set forth in ORS 426.385 if the individual is committed to the Authority; and

  Exercise all rights described in this rule without any form of reprisal or punishment.

Boysen Counseling, LLC (Family Roots Therapy)

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

-         Get a copy of your paper or electronic medical record

-         Correct your paper or electronic medical record

-         Request confidential communication

-         Ask us to limit the information we share

-         Get a list of those with whom we've shared your information

-         Get a copy of this privacy notice

-         Choose someone to act for you

-         File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

-         Tell family and friends about your condition

-         Provide mental health care

Our Uses and Disclosures

We may use and share your information as we:

-          Treat you

-         Run our organization

-         Bill for your services

-         Comply with the law

-         Address workers' compensation, law enforcement, and other government requests

-         Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

-         You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

-         We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

-         You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

-         We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

-         You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

-         We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

-         You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.

-         If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information

-         You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.

-         We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

-         If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

-         We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

-         You can complain if you feel we have violated your rights by contacting us using the information on page 1.

-         You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

-         We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

-         Share information with your family, close friends, or others involved in your care

-         Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

-         Marketing purposes

-         Sale of your information

-         Most sharing of psychotherapy notes

Our Uses and Disclosures 

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways - usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

-         Preventing disease

-         Helping with product recalls

-         Reporting adverse reactions to medications

-         Reporting suspected abuse, neglect, or domestic violence

-         Preventing or reducing a serious threat to anyone's health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

-         For workers' compensation claims

-         For law enforcement purposes or with a law enforcement official

-         With health oversight agencies for activities authorized by law

-         For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

-         We are required by law to maintain the privacy and security of your protected health information.

-         We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

-         We must follow the duties and privacy practices described in this notice and give you a copy of it.

-         We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the Terms of this Notice 

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

-         This notice is effective October 1, 2018

-         If you have questions about this notice, please speak with our Privacy Officer at 503-746-3373.

Grievance and Appeals

Family Roots Therapy values and encourages the feedback of our clients and community members about the programs and practices of the organization. Complaints can provide important opportunities for improving service. A complaint may be defined as an expression of dissatisfaction or unmet expectations. A complaint can be made by the service user or community member with support if necessary. The complaint can relate to any aspect of the organization's programs and services. A service user or community member who believes they have experienced discrimination at Family Roots Therapy may file a complaint or grievance with the Department of Medical Assistance Program (DMAP) or with the Oregon Board of Professional Licensed Therapists, following the procedures laid forth in the Service Informed Consent document.

Family Roots Therapy is committed to listening to client and community member complaints and responding in a fair, timely and respectful manner. All complaints will be given due consideration without reprisal or discrimination. Language support for non-English speaking service users or community members will be provided.  A grievant, witness, or staff member of a provider may not be subject to retaliation by a provider for making a report or being interviewed about a grievance or being a witness. Retaliation may include but is not limited to dismissal or harassment, reduction in services, wages, or benefits, or basing service or a performance review on the action. The grievant is immune from any civil or criminal liability with respect to the making or content of a grievance made in good faith.

All aspects of a complaint will be handled in confidence. However, if the complaint involves allegations of illegal or unethical behavior, information may need to be shared with external authorities.

All complaints are documented. The maintenance of complaint files is the responsibility of the Complaint Officer.

Complaints deemed a risk to the organization are brought forward to the owner. Clients with questions, comments, or complaints about Family Roots Therapy privacy policies and procedures or about the collection, use, or disclosure of their personal information will be directed to the Privacy Officer.

Complaint forms are provided at the Family Roots Therapy office, in the client portal in the "forms" section, or can be requested via e-mail at info@familyrootstherapy.com. 

Department of Medical Assistance Program (DMAP): 800-273-0557

Health Share of Oregon/CareOregon: 503-416-8090 TTY/TDD 800-735-2900

Trillium Community Health Plan: (877) 600-5472

Disability Rights Oregon: Voice: 503-243-2081  TTY users: dial 711

Health Systems Division: 503-945-5763

Governor's Advocacy Office (Ombudsman): 503-945-6904

Your insurance member services number listed in your member handbook

Our services are rendered at the full cost of $125/session for pre-licensed associates and $150/session for licensed providers when not using health insurance regardless of billing code.

If you are seen once per week, your estimated costs will be: 

$500/month (with 4 weeks of service) and $6500/year (with 52 weeks of service) if seeing a pre-licensed associate.

$600/month (with 4 weeks of service) and $7,800/year (with 52 weeks of service) if seeing a licensed provider.

If you are seen twice per week, your estimated costs will be:

$1000/month (with 4 weeks of service) and $13,000/year (with 52 weeks of service) if seeing a pre-licensed associate.

$1200/month (with 4 weeks of service) and $15,600/year (with 52 weeks of service) if seeing a licensed provider.

We offer a limited amount of sliding scale spots, so if the full rate is too great of a barrier, please reach out to our office staff to see what other options may be available.

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

The Good Faith Estimate is not a contract and does not require the uninsured (or self-pay) individual to obtain the items or services from any of the providers or facilities identified in the Good Faith Estimate.

Please sign below to agree to the terms and acknowledge receipt of this Good Faith Estimate.