Once an appointment is scheduled, please provide 24hours advance notice of cancellation. Missed appointments will be charged half the fee of the session ($52.50) if 24 hour notice is not given and will be charged to the client's credit card/ debit card on file. I will discuss with you any circumstances in which notice was unable to be given.

The fee for any therapy session is $105.

Payment is due at each therapy session. Payment is accepted in the form of cash, check, credit card, debit card, HSA, or FSA. Payment can also be paid through PayPal on the client secure area before sessions. I do not accept insurance. All payments made can be viewed through the client secure area. If a check is returned, there will be a $25 fee. In cases where children are in treatment and may live with two separate families, the parent who signs the paperwork at registration will be considered the responsible party for all client balances. The fees can change at any time. You will be asked to sign a new fee agreement if costs change.

LDS Clients:
I accept payment from LDS Bishops that I have consulted with concerning your treatment. I will bill Bishops directly for the amount that you have discussed with them after having a release form completed by you.

If you have any questions about this notice, please contact your therapist at 913-608-9616.

WHO WILL FOLLOW THIS NOTICE
This notice describes the practices followed your therapist regarding information gathered about you through the course of assessment and treatment.

YOUR MENTAL HEALTH INFORMATION
This notice applies to the information and records your therapist has about your mental health treatment and services you receive at this office. Your therapist is required by law to give you this notice. It will tell you about the ways in which she may use and disclose mental health information about you and describe your rights and our obligations regarding the use and disclosure of that information.

HOW YOUR THERAPIST MAY USE & DISCLOSE MENTAL HEALTH INFORMATION ABOUT YOU
Your therapist must have your written, signed consent to use and disclose mental health information for the purposes listed below. The policy is to ask your permission before releasing information to anyone outside of this office (except when services are provided in response to a court order), and to release the minimum amount of information to achieve the intended purpose.

- For Treatment: Your therapist may use mental health information about you to provide you with treatment or services. She may share information about you and disclose information to people in order to coordinate your care, such as assisting you to schedule an appointment with a psychiatrist.
- For Payment: Your therapist may use and disclose mental health information about you so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company, or a third party. For example, she may need to give your health plan information about a service you received so that your health plan will reimburse her for the service. Your therapist may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.
- For Operations: Your therapist may use and disclose mental health information about you in order to run her office and make sure that you and his other clients receive quality care. For example, she may use your mental health information to evaluate caring for you. She may also use mental health information about all or many of her clients to help her decide what additional services should be offered, how to be more efficient, or whether certain new treatments are effective.
- Appointment Reminders: Your therapist may contact you as a reminder that you have an appointment for treatment at the office. Please notify her if you do not wish to be contacted for appointment reminders.
- Business Associates: Your therapist may utilize some services through contracts with business associates such as maintaining your Electronic Medical Records. When these companies are contracted to perform services for Lori Crane LSCSW, LLC, your therapist may disclose your protected health information to these companies so that they can perform the job asked of them.  However, to protect your protected health information, we require the business associate to appropriately safeguard your protected health information.

You may revoke your consent at any time by giving your therapist written notice. Your revocation will be effective when she receives it, but it will not apply to any uses and disclosures that occurred before that time.
If you revoke your consent, your therapist will not be permitted to use or disclose information for purposes of treatment, payment, or operations, and your therapist may, therefore, choose to discontinue providing you with treatment and services.

SPECIAL SITUATIONS
Your therapist may use or disclose information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety: Your therapist may use and disclose information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Required by Law: Your therapist will disclose mental health information about you when required to do so by federal, state, or local law.

Workers' Compensation: Your therapist may release mental health information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness. When you request such benefits, access to related information is assumed.

Oversight Activities: Your therapist may disclose mental health information to a mental health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliances with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, your therapist may disclose information about you in response to a court or administrative order. Subject to all applicable legal requirements, he may also disclose information about you in response to a subpoena.

Information Not Personally Identifiable: Your therapist may use or disclose information about you in a way that does not personally identify you or reveal who you are.

OTHER USES AND DISCLOSURES OF MENTAL HEALTH INFORMATION
Your therapist will not use or disclose your mental health information for any purpose other than those identified in the previous sections without your specific, written authorization. She must obtain your authorization separate from any consent she has obtained from you. If you give her authorization to use or disclose information about you, you may revoke the authorization, in writing, at any time. If you revoke your authorization, she will no longer use or disclose information about you for the reasons covered by your written Authorization, but she cannot take back any uses or disclosures already made with your permission.

If she has HIV or substance abuse information about you, she cannot release that information without a written and signed authorization from you. In order to disclose these types of records for purposes of treatment, payment, or operations, she will have to have both your signed consent and a special written authorization that complies with the law governing HIV or substance abuse records.

YOUR RIGHTS REGARDING MENTAL HEALTH INFORMATION ABOUT YOU
Right to Inspect and/or Copy: You have the right to inspect and/or copy your mental health information that your therapist uses to make decisions about your care. There are limitations to this right. For example, you do not have the right to view therapy notes made by your therapist or material that is being accumulated in anticipation of a legal or court action. You must submit a written request to your therapist in order to inspect and/or copy your mental health information. If you request a copy of the information, your therapist may charge a fee for the costs of copying, mailing, or other associated supplies. She may deny your request to inspect and/or copy, in certain limited circumstances .If you are denied access to your mental health information, you may ask that the denial be reviewed. If law requires such a review, a Privacy Officer will review your request and the therapist's denial.

Right to an Electronic Copy of your Electronic Medical Records: You have the right to request to be given to you or transmitted to you or another individual or entity an electronic copy of your medical records, if they are maintained in an electronic format. Your therapist will make every effort to provide the electronic copy in the format you request. However, if it is not readily producible it will be given in either a standard format or hard copy form.

Right to Amend: If you believe information your therapist has about you is incorrect or incomplete, you may ask her to amend the information. You have the right to request an amendment for as long as this office keeps the information.

To request an amendment, complete and submit a Record Amendment/Correction Form to the Privacy Office/therapisr. Your therapist may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, she may deny your request if you ask her to amend information that:
- She did not create, unless the person or entity that created the information is no longer available to make the amendment
- Is not part of the information that she keeps
- You should not be permitted to inspect and copy
- Is accurate and complete

Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures your therapist has made of information about you for purposes other than treatment, payment, and operations. Information disclosed pursuant to a written Authorization from you, will not be logged. To obtain this list, you must submit your request in writing to your therapist. It must state a time period, which may not be longer than six years and may not include dates before April 14, 2003. There is no charge for providing the list.

Right to Request Restrictions: You have the right to request a restriction or limitation on the information your therapist uses or discloses about you for treatment, payment, or operations. She is not required to agree to your request. If she does agree, she will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you may complete and submit the Request for Restrictions On Use/Disclosure of Protected Health Information to your therapist.

Right to Request Confidential Communications: You have the right to request that your therapist communicate to you about mental health matters in a certain way or at a certain location. For example, you can ask that you only be contacted at work or by mail. To request confidential communications, you may complete and submit the Request for Restriction On Use/Disclosure of Protected Health Information and/or Confidential Communication to the Privacy Officer. The therapist will not ask you the reason for your request. She will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to Receive Notice of a Breach: Your therapist is required to notify you by first class mail or by e-mail (if you have indicated a preference to receive information by e-mail), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach. "Unsecured Protected Health Information" is information that is not secured through the use of a technology or methodology identified by the Secretary of the U.S. Department of Health and Human Services to render the Protected Health Information unusable, unreadable, and undecipherable to unauthorized users. The notice is required to include the following information:
- a brief description of the breach, including the date of the breach and the date of its discovery, if known;
- a description of the type of Unsecured Protected Health Information involved in the breach;
steps you should take to protect yourself from potential harm resulting from the breach;
- a brief description of actions he is taking to investigate the breach, mitigate losses, and protect against further breaches;
- contact information, including a toll-free telephone number, e-mail address, Web site, or postal address to permit you to ask questions or obtain additional information. 

In the event the breach involves 10 or more patients whose contact information is out of date, your therapist will post a notice of the breach on the home page of her web site or in a major print or broadcast media. If the breach involves more than 500 patients in the state or jurisdiction, she will send notices to prominent media outlets. If the breach involves more than 500 patients, your therapist is required to immediately notify the Secretary. She is also are required to submit an annual report to the Secretary of a breach that involved less than 500 patients during the year and will maintain a written log of breaches involving less than 500 patients.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask your therapist to give you a copy of this notice at any time. Even if you have agreed to receive it electronically, you are still entitled to a paper copy. You have access to this form via the online client secure area and this form can be printed out as well.

CHANGES TO THIS NOTICE
Your therapist reserves the right to change this notice, and to make the revised or changed notice effective for information she already has about you, as well as, any information she receives in the future. Your therapist will post a summary of the current notice in the office with its effective date in the top right hand corner. You are entitled to a copy of the notice currently in effect.

COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with your therapist or with the Secretary of the U.S. Department of Health and Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. To file a complaint with your therapist, contact her at 2300 Hutton Road Suite 112, Kansas City, Kansas 66109. All complaints must be submitted in writing and should be submitted within 180 days of when you knew or should have known that the alleged violation occurred. See the Office for Civil Rights website, www.hhs.gov/ocr/hipaa/ for more information. You will not be penalized for filing a complaint.

REQUIRED SIGNATURES
By signing below you acknowledge that you have reviewed this notice of privacy practices and that you have received this form electronically through the online client secure area at http://LoriCrane.client-secure-area.com.