patient disclosure
Washington Therapist
PATIENT DISCLOSURE STATEMENT
Leslie Fulp, MSW, LICSWA
100 N Howard St, Suite R
Spokane, WA 99201
re-formingwellness.com
lesliefulp@proton.me ⎸ 509-519-4172
Independent Practice
I am an independently contracted provider participating in the Mindful Therapy Group
Organized Health Care Arrangement (OHCA). While I have engaged Mindful Therapy
Group, P.C., a Washington Professional Services Corporation (Mindful Therapy Group),
to provide business administrative services to my behavioral healthcare business, all
services you receive from me reflect my own healthcare license, independent business,
and practice style. Mindful Therapy Group subcontracts with an affiliate company,
Mindful Support Services, LLC (Mindful Support Services), to provide a portion of the
administrative services.
I run my own business, re-forming wellness, and I contract independently with Mindful
Therapy Group. The support staff provide me with administrative assistance. Questions
regarding details of our work together should be directed to me. While Mindful and I
work in partnership, I set my own policies, including cancellation policies and private pay
rates. Often times, the administrative staff are messengers, providing you information
regarding insurance benefits, fees, and reminders of my personal established policies,
such as late cancellation fees. Therefore, please be mindful of being respectful to the
team when addressing any concerns. Abusive behavior toward Mindful Therapy Group
staff and myself is not tolerated and can result in immediate termination of services.
My License(s), Education and Training
I hold the following license(s) in the indicated state(s): Washington SWIA.SC.70012264
I am a Licensed Independent Clinical Social Worker Associate in the state of
Washington. I am being supervised by Ashley Bangs, LICSW, while working towards full
clinical licensure. I am committed to providing services that are person-centered,
equitable, and just. Further, I am legally bound and committed to the National
Association of Social Workers (NASW) code of ethics. As a licensed clinician, I am
required to participate in continuing education.
I hold a Bachelor of Science in Sociology with a focus on habilitation services and a
minor in Psychology. I have a Master of Social Work with a focus on community
organizing and social action from the University of Pittsburgh’s School of Social Work.
Additional information about my licensure is available at
https://fortress.wa.gov/doh/providercredentialsearch/
Patient Mix
I provide therapy services for individuals, families, and those in relationship. I see clients
ages 5+. I offer case management services, which includes but is not limited to
providing paperwork for disability, unemployment, custody, adoption, foster care, car
accidents and any type of legal issues. I offer therapy for individuals who are
court-mandated for treatment or seeking treatment in which disclosure of appointments
will need to be provided to an outside entity.
Treatment Modality and Therapeutic Orientation
I approach each person/client individually using a person-centered approach. Based on
the client’s goals, a treatment plan will be created and followed throughout the course of
treatment. Our exchange is reciprocal in nature, as you are the expert of your life. I am
not a doctor treating symptoms, and I’m not here to “fix” but an ally and resource for you
to utilize in meeting your personal goals and improving the quality of your life–However
that may look for you. I will approach our relationship professionally, therapeutically, and
collaboratively.
Therapy has both benefits and risks. During the course of therapy, you might notice
changes in your symptoms, problems, and functioning. Since we will be exploring
challenging territory in your life, you might experience greater difficulty throughout our
work. Therapy typically produces benefits over time, but sometimes as you get to the
root of tender issues, you may feel them even more acutely than in the past. I cannot
offer any promise or guarantee about the results you will experience. However, as you
commit yourself to work through your vulnerable issues and build upon your strengths, it
is likely that you will see improvements throughout our work and in the future.
New Patients
There will be 1-2 initial visits to ensure proper assessment and thorough evaluation.
Appointment(s) are 53 minutes. These appointments will be used to evaluate, educate,
and determine a mental health diagnosis. I may want to see you weekly until either your
symptoms are alleviated or your condition is stabilizing. We will work together to
determine the best frequency of appointments going forward based on your health,
treatment goals and stability of your condition.
If you have previous mental health records and/or contacts you would like me to have
regarding your previous care, please provide that information. I will need to collect a
Release of Information before making contacts.
Cancelling Appointments
In order to provide you with optimal care, your appointment time is reserved specifically
for you. I do not double-book clients. In return, I ask that you provide our front office with
a minimum of 48 hours’ notice if you are unable to make it to your appointment.
Cancellations made without 24 hours advance notice will incur late cancellation fees
(see Patient Disclosure for more details). Please call Mindful Therapy Group's front
office staff for all scheduling needs at (425)-640-7009 to ensure prompt attention.
Rescheduling Appointments
If you need to reschedule an appointment, the rescheduling request should be made
with Mindful Therapy Group, not me. If you need to reschedule an appointment, I ask
that you give Mindful Therapy Group at least 48 hours’ notice in advance of the
originally scheduled appointment. Rescheduling requests made without 24 hours
advance notice will incur late cancellation fees.
I work with all my clients on a recurring, weekly, or bi-weekly basis. If you cancel several
appointments, I will ask that you be removed from your recurring appointment slot and
be placed on my on-call list, as repeated cancellations present a barrier to the
therapeutic process. If you are on the on-call list, I will reach out to you as appointments
become available. If you have repeated no-show appointments, upcoming scheduled
appointments may be cancelled.
Mindful Therapy Group and/or I will make every effort to provide you with adequate
notice if I will be unavailable for a scheduled appointment.
Vacations
If you are going on vacation please notify me as soon as possible. I require 48 hours’
notice for cancellation of your appointment.
Emergencies
I am not available on an emergency basis. If you are experiencing an emergency or are
concerned you may be a threat to yourself or others, please dial 988 (an emergency line
specific to suicide and mental health crises) or 911 or go to the nearest hospital
emergency room.
Contact for Administrative/Scheduling Questions
If you have questions about scheduling, billing or technology, please contact Mindful
Therapy Group at:
frontdesk.wa@mindfulsupportservices.com
scheduling.wa@mindfulsupportservices.com
425-640-7009
Requests for Consultation
If you need a consultation outside of a scheduled appointment, please direct your
request to me via email or phone number listed. Mindful Therapy Group administrative
staff are not clinically trained and are unable to respond to requests for consultation.
In-Network Insurance
Mindful Therapy Group will be handling adminstrative tasks, including insurance and
billing. Below are the insurances I currently accept.
Aetna
Cigna and Evernorth
Kaiser (Out-of-Network)
Premera Blue Cross
Regence
UnitedHealthcare UHC | UBH
Private pay is accepted
Payment Options
Payments including copays, coinsurances, deducibles, and private pay clients must be
made prior to starting appointment or within 24 hours of service. If payment is not
received within 24 hours a $3 late fee will be added to the charge daily. If late payments
are consistent for several visits, you will be required to pay before the session begins. If
an account holds a past due balance, therapy sessions will be ceased until payment is
received.
Please contact your insurance provider if you have any questions regarding these fees,
as these fees are not determined in the practice. Advanced payment can be discussed
with myself and the administrative team, as well as any requests for refunds. I reserve
the right to cancel or reschedule the appointment if you are not prepared to pay.
Communication
I use email communication only for administrative purposes. I do not provide clinical
support via this method. That means that email exchanges should be limited to things
like requesting communication between sessions and notifying me of a cancelled
appointment.
The most effective time to address concerns is during session, as this is time which is
dedicated to your care. You will likely receive a faster response through Mindful Therapy
Group when I am unavailable. However, you may also contact me through my direct
number and will attempt to return your call within one business day. I will respond to
your emails within 48 hours. Please contact the mental health crisis line at 988 or call
911 if you are in crisis.
Confidentiality
All information disclosed within appointments is confidential. I keep brief notes of our
appointments but such notes and other information related to these appointments will
not be disclosed to anyone except as permitted or required by law.
If you would like me to collaborate with others on your care, a Release of Information
will be required.
Couples & Families
I greatly value transparency. I have a “no secrets” policy when working with families and
couples. It is not ethically aligned with therapy. If you have questions or concerns about
this policy, please let me know and we can discuss this further.
Notice of Privacy Practices
The Mindful Therapy Group Organized Health Care Arrangement Notice of Privacy
Practices describes how medical information about you may be used and disclosed and
how you can get access to this information. An electronic copy of the Notice of Privacy
Practices can be found here.
Your Rights
You have the following rights
●To refuse treatment
●To choose a practitioner and treatment modality which best suits your needs
●To expect that I have met the qualifications of training and experience required
by state law
●To examine public records maintained by the state authority that licenses me
and to have such authority confirm my credentials
●To obtain a copy of the code of ethics to which I am bound
●To be informed of the cost of my services before receiving the services
●To be assured of privacy and confidentiality while receiving services from me
(note-the law sometimes permits or requires disclosures of private/confidential
information)
●To be free from discrimination because of age, color, culture,
disability, ethnicity, national origin, gender, race, religion, sexual orientation,
marital status, or socioeconomic status
●To report complaints to the state authority that licenses me contact:
Washington’s Department of Health
Town Center 2, 111 Israel Rd. SE, Tumwater, WA 98501
360-236-4700 or hsqa.csc@doh.wa.gov
Patient/Parent/Guardian Acknowledgment and Consent to Mental Health
Treatment
I (the patient or the patient’s parent legal guardian) have been provided a copy of my (or
my child’s) provider’s disclosure statement. I have read and understand the information
provided. I consent (or consent on my child’s behalf) to receive mental health services
from the provider named in this Disclosure Statement.
Patient Name:
Patient Date of Birth:
* If patient is under the age of 18 the patient’s parent or legal guardian must sign below
unless a minor patient is requesting to be assessed as a mature minor in accordance
with state eligibility guidelines
Signed:
Print Name:
Relationship to Patient (e.g., self, parent):
TELEHEALTH CONSENT
As a client of Mindful Therapy Group, I acknowledge that I will have the opportunity, but
not the obligation, to utilize a video conferencing platform (i.e. Telehealth) for sessions
with my provider. Using Telehealth is at the mutual discretion of my provider and I.
• In utilizing Telehealth, I agree to participate in technology-based sessions with my
Provider, and I authorize information related to my health to be electronically transmitted
in the form of images and data through an interactive video connection to and from my
Provider and other persons involved in my health care.
• I represent that I am using my own equipment to communicate and not equipment
owned by another and am specifically not using my employer’s computer or network. I
am aware that any information I enter into an employer’s computer can be considered
by the courts to belong to my employer and my privacy may thus be compromised.
• I have read this document carefully and fully understand the benefits and risks. I have
had the opportunity to ask any questions I have and have received satisfactory
answers. With this knowledge, I voluntarily consent to participate in Telehealth sessions,
including, but not limited to, care, treatment, and services deemed necessary and
advisable, under the terms described herein.
Patient Name:
Patient Date of Birth:
* If patient is under the age of 18 the patient’s parent or legal guardian must sign below
unless a minor patient is requesting to be assessed as a mature minor in accordance
with state eligibility guidelines
Signed:
Print Name:
Relationship to Patient (e.g., self, parent):
ARTIFICIAL INTELLIGENCE
Artificial Intelligence (AI) tools may be integrated into your sessions to complement the
therapeutic process. Your privacy and confidentiality while utilizing AI tools are of utmost
importance. Any data inputted into AI tools will be securely stored according to HIPAA
privacy guidelines.
I have read and understood the above information and consent to the utilization of AI to
support the therapeutic process. I understand that my consent is voluntary, and I have
the right to withdraw my consent at any time.
Patient Name:
Patient Date of Birth:
* If patient is under the age of 18 the patient’s parent or legal guardian must sign below
unless a minor patient is requesting to be assessed as a mature minor in accordance
with state eligibility guidelines
Signed:
Print Name:
Relationship to Patient (e.g., self, parent):
FINANCIAL RESPONSIBILITY
Insurance Fees
I am in-network with a select number of insurance companies for my services. Please
provide full insurance information and your insurance card upon your initial visit (or
before, if possible) so we can determine the benefits for which you are eligible. If you
have a change in insurance, please let us know as soon as possible.
Your insurance plan may require me to assess you a copayment, coinsurance or
deductible (“cost share”). Mental health appointments are assigned billing codes on
claims that vary based on factors such as appointment length and complexity. As a
result, your cost share may vary from visit to visit.
I am in-network with a select number of insurance companies for my services. Please
provide full insurance information and your insurance card upon your initial visit (or
before, if possible) so we can determine the benefits for which you are eligible. If you
have a change in insurance, please let us know as soon as possible.
Your insurance plan may require me to assess you a copayment, coinsurance or
deductible (“cost share”). Mental health appointments are assigned billing codes on
claims that vary based on factors such as appointment length and complexity. As a
result, your cost share may vary from visit to visit.
Any cost share is due at the time of service. Mindful Therapy Group staff and I will do
our best to estimate your cost share in advance of or at the time of your appointment.
However, it is possible that your insurance plan, after reviewing the claim, will determine
that your cost share is higher than we estimated. In these situations, Mindful Therapy
Group will notify you about any balance due with a monthly statement. In the event we
overestimate the cost share, the credit will be applied towards your future visits, unless
you specify otherwise.
If your insurance plan requires preauthorization for services, it is your responsibility to
obtain this authorization prior to our appointment. If you fail to obtain authorization, any
and all charges incurred for services rendered by me and not reimbursed to me or
Mindful Therapy Group by your health insurance will be your financial responsibility.
Private Pay (Self-Pay) Fees
●Individuals $110 per 55-minute session
●Couples/Families $160 per 55-minute session
Case Management Time Fees
Most clinical issues should be shared in our appointment. If calls and case management
become excessive, I may need to charge for case management time. I will always
inform you prior to providing this service and before billing for it.
●$100 per hour
Cancellation Fees
If you are unable to provide more than 24 hours’ notice, you will incur a missed
appointment/late cancellation fee as follows:
●$110 (individuals) $160 (families), less than 24 hours' notice
While I will consider special circumstances, this charge is irrespective of the reason for
the cancellation/no show. Insurance does NOT cover this fee and will automatically be
charged to the credit card listed on file. I understand unexpected things sometimes pop up. If there is a pattern noticed of
cancelled appointments, I may be unable to continue providing services to you, and I
reserve the right to cancel future appointments in order to make room for clients
committed to the therapeutic process. I will always communicate about this with you and
determine if we’re a good fit prior to making changes to our scheduled appointments.
Washington Apple Health (Medicaid) Billing
In accordance with WAC 182-502-0160, if you are using Washington Apple Health
(Medicaid) to cover services, I may not bill you for the following:
●Services covered under your Apple Health plan, even if I have not yet been paid.
●Services denied because of provider error (such as missing prior authorization or
required documentation).
●Missed, canceled, or late appointments.
You may only be billed for services that Apple Health does not cover if you sign
an “Agreement to Pay for Healthcare Services” before receiving those services. If
Mindful Therapy Group is not contracted with your Apple Health plan, you may
be responsible for fees and any cost-sharing as determined by your plan.
For more details, please refer to your Apple Health plan documents or applicable
Washington regulations.
Collections
If you have an unpaid patient balance of $100 for more than 120 days, the
balance may be turned over to a third-party collections agency. You will receive a
final courtesy phone call and/or letter to remind you of your balance due. If you
believe that there is an error in your billing, please let us know as soon as
possible so we can research the issue. Unpaid balances without a payment plan
or partial payment initiated after 120 days will initiate a phone collections effort
for recovery, and some identifying confidential information will be released in this
process. This may negatively impact your credit. It is very important that you
update your contact information with us to ensure you are aware of your financial
responsibility and receive your statements.
Assignment of Benefits
In exchange for, and in connection with, any and all of the services provided to
you or your child, as applicable, by your Provider, you irrevocably assign and
transfer to Mindful Therapy Group and your Provider all of the rights, benefits,
privileges, protections, claims and any other interests of any kind whatsoever,
without limitation, that you or your child, as applicable, had, have or may have in
the future pursuant to or in connection with any health insurance policy or plan,
health benefit plan, health management agreement, healthcare risk-bearing
agreement, healthcare trust, healthcare fund or any other source of payment,
healthcare insurance, healthcare indemnity or health or medical coverage of any
kind covering you or your child, as applicable to healthcare. This assignment also
includes assignment of your or your child’s, as applicable, appeal rights, fiduciary
rights, rights to sue, rights to payment, rights to full and fair claims review, rights
to penalties or interest, rights to plan documents and plan information, and rights
to notices and disclosures from any source.
Patient Name:
Patient Date of Birth:
* If patient is under the age of 18 the patient’s parent or legal guardian must sign below
unless a minor patient is requesting to be assessed as a mature minor in accordance
with state eligibility guidelines
Signed:
Print Name:
Relationship to Patient (e.g., self, parent):