Ramos Integrative Psychological

Services, LLC.
Consent to Treatment & Evaluation Obligations of Treating Provider
The information you share will be treated with great care. It is your legal right that your sessions and records about
you are kept private. You will need to sign a “release-of-information” form before your provider can talk about you or
send your records to anyone else. In general, your provider will tell no one what you share in confidence. Your
provider will not even reveal that you are receiving treatment from Ramos Integrative Psychological Services, LLC.
without your prior written permission to do so. In most situations, your confidentiality (privacy) is protected by state
law and by the rules of our profession; however, there are a few exceptions in which confidentiality is not protected:

1. If you make a serious threat to harm yourself (i.e., suicidal threat) or another person (i.e., homicidal
threat), the law requires that your provider try to protect you or the other person. This typically means telling
others about the threat to ensure your safety or the safety of a potential victim. The law does not require
your provider to disclose you are having/discussing thoughts of suicide or homicide; however, your provider
will break your confidence if she believes that you intend to carry out a suicide or homicidal plan.

2. If your provider has reasons to suspect, based on her professional judgment, that a child is/has been
abused, she is required to report her suspicions to the authority or government agency vested to conduct
child abuse investigations. Your provider is required to make such reports even if she does not see the child
in her professional capacity. Your provider is mandated to report suspected child abuse if anyone aged 14 or
older tells the provider that he/she committed child abuse, even if the victim is no longer in danger. Your
provider is also mandated to report suspected child abuse if anyone tells the provider that he/she knows of
any child who is currently being abused.

If you were sent to the practice by a court or an employer for evaluation or treatment, the court or employer expects
a report from your provider. If this is your situation, please speak with your provider before you disclose anything
you do not want the court or your employer to know. You have a right to disclose only what you are comfortable with
sharing. Are you suing someone or being sued? Are you being charged with a crime? If so, and you tell the court
that you are being seen by this practice, your provider may then be ordered to show the court our records. Please
consult your lawyer about these issues.

Consent to Treatment
I do hereby seek and consent to take part in my treatment and/or evaluation. I understand that developing an initial
treatment plan or goals for the evaluation and regularly reviewing our work toward meeting the treatment goals are
in my best interest, and I agree to play an active role in this process. I understand that no promises have been made
to me as to the results of my treatment or evaluation, or of any procedures provided by Ramos Integrative
Psychological Services, LLC. I am aware that I may stop my treatment at any time. I will still be responsible for
paying for the services I have already received. I understand that I may lose other services or may have to deal with
other problems if I stop treatment. (For example, if my treatment has been court-ordered, I will have to answer to the
court.) I also have the right to ask questions about my therapist’s clinical background and qualifications, or questions
about any procedures or methods used in treatment, as well as possible alternative methods of treatment. My
signature below demonstrates that I understand and agree with all these statements.

______________________________________ ___________
Signature Date
______________________________________

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Printed Name

Ramos Integrative Psychological

Services, LLC.
Services and Fees
 Psychiatric Diagnostic interview
o 60 minutes (CPT code 90791): $180
o 90 minutes (CPT code 90791): $270
 When a client has medical and/or behavioral health complexities.
 Individual therapy
o 30 minutes (CPT code 90832): $90
o 45 minutes (CPT code 90834): $135
o 60 minutes (CPT code 90837): $180
 Couples or Family Therapy
o 60 minutes (CPT code 90847 or 90846): $180
 Crisis Psychotherapy (complex/life-threatening circumstances that require immediate attention)
o First 60 minutes (CPT code 90839): $180
o Each additional 30 minutes (CPT code 90840): $90
 Court related work (e.g., preparation of letters and evaluations, testimony, travel time, time away from
office due to legal proceedings and review of records for legal purposes): $180 per hour
 Telephone consultation with professionals, non-routine paperwork (e.g., FMLA/disability paperwork),
review of medical records >5 minutes: prorated at $180 per hour.
 Missed/No show appointments (less than 48-hour notice): $60.
 Phone calls
o 10-15-minute phone call: $15
o 15-25-minute phone call: $30

You are responsible to pay the full fees as listed above. Upon request, you will be provided with a statement
for any services rendered, which you may submit to your insurance for reimbursement if your policy has “out of
network” benefits.
Payment: Payment is due at the beginning of each session unless other arrangements have been made.
Payment options include Visa, MasterCard, Discover, American Express, and HSA/FSA cards are accepted.
For your convenience, you may complete a credit card authorization form that authorizes Ramos Integrative
Psychological Services, LLC to make payments on your account in accordance with this agreement.
You agree to accept financial responsibility for any missed appointments not canceled within 48-hours of your
scheduled appointment time. The missed appointment or late cancellation fee is $60.

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Late Payment Fee: A $10 late fee will be added to your account if payment is not received within 30 days upon
receipt of a bill for your account.

Ramos Integrative Psychological

Services, LLC.
Financial Hardship: You agree to contact the practice to establish a payment plan if you are experiencing
financial challenges that make it difficult for you to pay your bill or request an application for a reduced fee for
service(s).
Non-payment: Account statements shall be deemed accepted by you unless we are notified in writing within 14
days of the statement being issued that you dispute the charges. You also acknowledge that your account may
be referred to IC System, a national collection agency if your account becomes 90 days past due. You will be
notified of our intent to do so in advance and will be offered the opportunity to settle your account to avoid
being sent to collections. By virtue of this agreement, you are providing your consent to release your account
balance and necessary contact information (name, address, date of birth, social security number) to IC System
to collect your debt should that become necessary. Please be aware that if your account continues to be
unpaid, IC System is authorized to report all outstanding debts to the four major national credit agencies. In the
event your account is sent to collections, you will be charged legal and debt collection fees incurred by Ramos
Integrative Psychological Services, LLC. in relation to the recovery of outstanding debt, which is 35% of the
balance due on your account.
Privacy Notice: Please refer to the “Notice of Privacy Practices” or “HIPPA Notice” for more specific
information which will be provided at the end of this packet. You are entitled to receive a paper copy upon
request.
I have carefully read, understand, and agree with all the terms of this agreement and agree to abide by its
guidelines. I have had an opportunity to ask questions and I acknowledge that I may receive a copy of this
agreement upon request.
__________________________________ ___________________
Signature of Client Date

Authorization to Release Information to Primary Care Physician

Ramos Integrative Psychological Services, LLC. believes that coordination of care with your family
doctor/primary care provider is an important part of your treatment. There may be times when it is necessary to
discuss emotional or behavioral factors that impact your physical health or consult about medication. At times it
may be beneficial to speak with your doctor to better understand your medical problems and how they may be
impacting you. Even if you do not have any current medical issues, having your permission to communicate
with your doctor enables your provider to be proactive in addressing concerns that may come up in the future.
You reserve the right to decline your consent, which can be indicated below. By selecting the “I consent” option
signing this form, you are authorizing Ramos Integrative Psychological Services, LLC. to share information in
your treatment record, either verbally or in writing to enhance your overall treatment experience.
I understand that I have the right to revoke consent to future disclosure in writing at any time; however, this
revocation will not be effective to the extent that I have already acted in reliance on this authorization, or if this
authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to
contest a claim. I understand that my treatment generally may not be conditioned on signing a release of
information unless the services are provided to me for the purpose of providing information to a third party.

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Federal rules prohibit re-disclosure of information to another party unless expressly permitted by the written
consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. I acknowledge that I
have had the opportunity to discuss and ask questions about issues concerning privacy and confidentiality and

Ramos Integrative Psychological

Services, LLC.
this consent. This authorization will remain in effect until my discharge from treatment unless otherwise
revoked in writing at a future point in time.
Please select one:
_____ I do want to share any information with my doctor currently.
_____ I do not want to share any information with my doctor currently.

________________________________________ ________________
Client Signature Date

________________________________________ ________________
Printed Name Date of Birth

________________________________________ ________________
Signature of Witness Date

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 Ramos Integrative Psychological
Services, LLC.
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. RAMOS INTEGRATIVE PSYCHOLOGICAL
SERVICES, LLC. IS REQUIRED BY LAW TO PROVIDE YOU WITH THIS NOTICE. PLEASE REVIEW IT
CAREFULLY.
In general, the practice may not use or disclose protected health information except: ● To you ● With your
written consent to carry out treatment, payment or health care operations ● With your written consent in other
circumstances when an authorization is required. Psychotherapy notes may not be used or disclosed without
your specific consent except ● For use by your therapist ● By the practice to defend a legal action or other
proceeding brought by you. Psychotherapy notes: “Psychotherapy notes” means notes recorded (in any
medium) by a health care provider who is a mental health professional documenting or analyzing the contents
of conversation during a private counseling session or a group, joint, or family counseling session and that are
separated from the rest of the individual’s medical record. Psychotherapy notes excludes medication
prescription and monitoring, counseling session start and stop times, the modalities and frequencies of
treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional
status, the treatment plan, symptoms, prognosis, and progress to date” (45 CFR § 164.501). Your provider is
required to disclose protected health information to you when your request meets the requirements of a proper
request, and to the Secretary of Health and Human Services when required to investigate or determine
compliance with these Regulations. Ramos Integrative Psychological Services, LLC. must make reasonable
efforts to limit the disclosure to the minimum information necessary to accomplish the purpose of the use,
disclosure or request. If Pennsylvania State law or other applicable regulations are more stringent than these
Regulations, the practice must follow the more stringent rules with regard to use and disclosure. If these
Regulations are more stringent than State law(s), the practice must follow these Regulations. You have the
right to request restrictions on certain uses and disclosures of protected heath information. However, the
practice is not required to agree to a restriction you request. If the practice agrees to a restriction this must be
documented and abided by it unless the information is needed by another health care provider to provide you
emergency treatment. The practice may use or disclose your protected health information without your written
consent or authorization or without providing an opportunity for you to agree or object ● For mandating
reporting of child or elder abuse if your provider has reason to suspect, on the basis of her professional
judgment, that a child is or has been abused, she is required to report her suspicions to the authority or
government agency vested to conduct child abuse investigations. Your provider is required to make such
reports even if she do not see the child in her professional capacity. Your provider is mandated to report
suspected child abuse if anyone aged 14 or older tells her that he/she has committed child abuse, even if the
victim is no longer in danger. Your provider is also mandated to report suspected child abuse if anyone tells
her that he/she knows of any child who is currently being abused. ● Reporting of impaired drivers ● To avert a
serious threat to health or safety ● For worker’s compensation and disability claims ● Other allowable
circumstances (e.g., responding to a court order, etc.) You have the right to inspect and copy protected health
information except: ● Psychotherapy notes ● Information compiled in reasonable anticipation of, or for use in, a
civil, criminal, or administrative action or proceeding. In rare circumstances, Ramos Integrative Psychological
Services, LLC. may deny you access to protected health information. For example ● If access is reasonably

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likely to endanger your life or physical safety or someone else’s life or physical safety ● The information refers
to another person and access requested is reasonably likely to cause substantial harm to that other person or

Ramos Integrative Psychological

Services, LLC.
● If providing the information to your personal representative is reasonably likely to cause that person or
another person substantial harm. ● In most cases when access is denied, you may request a review of the
denial. If you request a review, the review will be completed by a licensed health care professional that has
been designated for this purpose and who did not participate in the original decision to deny access. Your
provider must abide by that person’s determination. Other uses and disclosures of your protected health
information will be made only with your written authorization. You may revoke such authorization at any time
provided you do this in writing and the practice has not already acted on your prior consent, or if the
authorization was obtained as a condition of obtaining insurance coverage and other law provides the insurer
with the right to contest a claim under the policy. Additional Rights & Information: ● You have the right to
amend your protected health information. ● You have the right to receive an accounting of disclosures made of
your protected health information. ● You have the right to receive a paper copy of this Notice upon request.
●The practice is required to abide by the terms of this Notice currently in effect. ● The practice is required to
provide this Notice to you no later than the date of first service(s) to you after these go into effect. ● In order to
apply a change in a privacy practice described in this Notice, the practice will provide you with a Revised
Notice at your next scheduled visit after the revision, and by a paper copy upon your request. ● The practice
must implement policies and procedures related to this Notice and the Privacy Regulations and maintain those
policies and procedures in written or electronic form. You may file a complaint with the practice or with the
Secretary of Health and Human Services if you believe your privacy rights have been violated. Ramos
Integrative Psychological Services, LLC. will provide you with a form for filing this complaint with the practice,
and you will not be retaliated against for filing such a complaint. To file a complaint contact Dr. Alexandra
Duncan-Ramos, at 210 Crossings Blvd., PMB#175, Elverson, PA 19520 for further information and/or to
request a “Violation of Privacy Rights Complaint Form.” If there is a breach of your confidentiality, then the
practice must inform you as well as Health and Human Services. A breach means that information has been
released without authorization or without legal authority unless the practice (the covered entity) can show that
there was a low risk that the PHI has been compromised because the unauthorized person did not view the
PHI or it was de-identified. ● If you are self-pay, then you may restrict the information sent to insurance
companies. ● Most uses and disclosures of psychotherapy notes and of protected health information for
marketing purposes and the sale of protected health information require an authorization. Other uses and
disclosures not described in the notice will be made only with your written authorization. ● You must sign an
authorization (release of information form) for releases unless it is for purposes already mentioned in this
Privacy Notice (such as mandated reporting of child abuse, reporting of elder abuse, reporting of impaired
drivers, etc.). ● You have a right to receive a copy of your Protected Health Information in an electronic format
or (through a written authorization) designate a third party who may receive such information. ●Ramos
Integrative Psychological Services, LLC. ●210 Crossings Blvd., PMB #175, Elverson, PA 19520 ● (610) 550-
3224.

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 Ramos Integrative Psychological
Services, LLC.
Authorization for Release of Information

I _____________________________________, born on ______________, hereby authorize:

Ramos Integrative Psychological Services, LLC.

210 Crossings Blvd.
PMB # 175
Elverson, PA 19520
(610) 550-3224

To release and/or obtain, the following information in my records:

_____ Mental health and medical history, including diagnosis.

_____ Records of outpatient mental health treatment, including progress notes, psychiatry notes, psychological
assessment/testing notes.
_____ Verbal coordination of care.
_____ Other: ______________________________________________

Information is to be _____ released to or _____ obtained from:

Facility/Provider Name: ________________________________________

Address/Phone: ______________________________________________
_______________________________________________
This information is to be released for the following purpose(s):

_____ Treatment planning and coordination of care.

_____ At the request of the individual or authorized agent.
_____ Coordination of care.
_____ Other: ______________________________________________

I understand that I have the right to revoke consent to future disclosure in writing at any time; however, this revocation will not be
effective to the extent that I have already acted in reliance on this authorization, or if this authorization was obtained as a condition of
obtaining insurance coverage and the insurer has a legal right to contest a claim. I am further aware that this information used or
disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer protected by the Privacy Rule. I
understand that my treatment generally may not be conditioned on signing a release of information unless the services are provided to
me for the purpose of providing information to a third party. I acknowledge that I have had the opportunity to discuss and ask questions
about issues concerning privacy and confidentiality and this consent. Confidential medical information which will not be used for
treatment will not be released.

This authorization will remain in effect for the duration of this episode of care unless otherwise indicated below:

___________________________________________________________

__________________________________________ _______________

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Signature Date

__________________________________________
Printed Name

__________________________________________ _______________
Signature of Witness Date

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