Thomas A. Peltz Home Page

Thomas A. Peltz, LMHC, LADC-1, CAS, CPE-1, M.Ed.

OFFICE: PO Box 2031, So. Hamilton, MA 01982

Phone: 978-927-6763

FAQ: Therapeutic Treatment Agreement

Thomas A Peltz • My therapist is a mandated reporter of neglect, harm, or abuse to minors; the elderly; and to all persons considered handicapped. Also, he will report suspected cases of threat or harm to self or others. Permission to report is not required in these above stated circumstances.

Thomas A Peltz • My therapist will maintain all standards of confidentiality as required by federal and state legal and professional standards. Written “Releases of Information” will be requested of the patient when needed - such as for PCP's, family, or other parties involved with the care of the patient; and unless otherwise requested, all releases will remain in effect until your case is closed. A patient will be notified if their PHI (Personal Health Information) has been compromised; and no data will be used by the therapist for fundraising, marketing, or sale. Further, the patient may restrict the disclosure of PHI if the patient has paid in full for the health care item/service out-of-pocket. My therapist may request outside clinical supervision, and/or professional insurance billing or administrative staff support services without a “Release of Information” in order to perform his normal business practice duties.

• Use of email, text, cellphone and other electronic forms of communication with therapist may not be covered under HIPPA encryption standards, and by your using these forms of communication, you acknowledge and accept this understanding, and thereby wave such encryption requirements.

• Appointments will be attended on time. At least forty-eight (business day) hours is required for the rescheduling of appointments, or I may be responsible for a “No Show” at the full rate payment fee. If you do not contact me, I will assume after 12 minutes that you are not coming, and this hourly rate is $150.00. Insurance will not cover such an expense. Two missed appointments may result in termination of treatment with me and a referral to another provider of mental health care. Finally, unless otherwise arranged, if 'no contact' occurs, I will move to close your case on or after 45 days of your last appointment with me.

Thomas A Peltz • Full payment and/or co payments are due in the form of cash or a check at the time of treatment, unless other arrangements have been made in advance. You will be fully responsible for any extra expenses which might occur outside of 'normal clinical duties' such as: legal expenses, returned check processing fees, paperwork, and/or telephone contacts. My sliding scale fee structure hourly rates are not difficult to decide what meets your needs. My 'Full' ($170-150), or 'Moderate' ($150-100) and 'Minimum' ($90-80) fee rates are based by you on your ability to pay. I am fair to you, and I trust you will be fair to me. You then decide and can estimate what you will pay. The frequency you decide to use is of course always something we will discuss together, and so you control the service costs. If there is a dispute about a bill, please contact me and share your concern. Different rates may exist for your insurance company, physician, or other referred programs than my contracted fee structure and/or co-payment responsibilities. Because each plan is different, you would have to contact your insurance company or other provider to learn of those rates. I will submit to you a monthly Invoice for the services I provide, unless otherwise arranged. If you pay privately, you may choose to submit the Invoice to your insurance provider for Out-of-Network reimbursement, which would be directly paid to you at the rate they agreed to. (Remember, this amount may differ from the agreed to charge you have made with me.)

• No therapy will be offered if prior alcohol, use of marijuana, or illicit drug use occurred on the day of the scheduled treatment session.

• Violence will not be tolerated, may result in the termination of therapy with my therapist, and/or legal charges.

• Should clinical emergencies arise, the patient will immediately report to the local hospital emergency room and ask that physician to notify therapist regarding the outcome; and/or the patient will contact 911 for assistance. Other numbers to contact include: 24 Hour Mental Health Crisis Services: 978-744-1585, National Poison Control Hotline: 800-222-1222, National Suicide Prevention Lifeline: 800-273-8255, Samaritans Hotline: 877-870-4673. Attempts will be made by the therapist to return patient communication in a timely manor however, do not wait for the therapist to contact you.

• Again, if urgent care is needed dial 911 or contact the local hospital for assistance.

• Normal times of operation are: Tuesday-Thursday 9:00a - 5:30p. (Other hours scheduled with special arrangement.)