Ann Duvall MA, NCC, LPC
Client Information


PAYMENT INFORMATION

I ask for payment at the time of the session unless a specific arrangement is made in advance. Except for emergencies, 48 hour notice is required to cancel an appointment without being charged for the session.


PRIVACY and CONFIDENTIALITY

The Health Portability and Accountability Act of 1986 (HIPPA) stipulates what a healthcare practitioner can and cannot do without your authorization. Under HIPPA, a healthcare practitioner CAN release information to your health insurance company or physicians for treatment purposes, payment or health care operations without your express permission. However, information CANNOT be divulged to employers, family friends or any businesses other than your insurance company without your permission. Confidentiality is maintained with those stated above unless there is clear and imminent danger to yourself or to another person, or in cases of child abuse and neglect or court orders.
I will not release any written information (notes, statements for payment, assessments or this intake form) without first getting written permission from you. Your signature below indicates you have been informed of the information stated above.