To discuss your counseling and therapy needs and set up an appointment to begin the process of therapy, please contact Robyn Brickel, the Clinical Director of the practice, via phone 703-518-8883 or email. During that initial contact, we will ask some questions to get to know your needs and if we are appropriate care providers, we will provide you the link for our new client information forms and our therapy portal.
Below is a link to our HIPAA approved electronic health record, TherapyNotes for established clients. Once you establish a client portal, you will have access to our needed new patient/client forms, as well as a returning client form (if you are returning to therapy less than one (1) year since your last appointment), in electronic versions.
As a current client, you will also have access to update your forms at any time, such as: our Release of information form or Change of Contact Form.
We ask that you read, review and sign these forms in order to schedule an initial appointment with our practice.
Click the button below to access the following forms:
Please note that making an initial contact with the practice does not necessarily begin a therapy/counseling relationship with this office. Therapy/counseling begins after the initial evaluation in our office and the new patient forms packet is completed and accepted by our office. At that time, you and the therapist will both evaluate this information and assess whether or not we are the appropriate provider for your therapy/counseling needs and if you want to work with our office going forward.
Client Rights and Policies
At Brickel and Associates, LLC we strive to ensure we are upholding your rights as a client through our policies and procedures. We are committed to following all Federal and State laws and regulations. Please review this information and the information provided in your new patient forms notifying you of your rights as a client along with our office policies.
No Surprises Act and Good Faith Estimates
YOU HAVE THE RIGHT TO RECEIVE A “Good Faith Estimate” EXPLAINING HOW MUCH YOUR MEDICAL CARE WILL COST
Under the law, the No Surprises Act of the 2021 Consolidated Appropriations Act that went into effect January 1, 2022, healthcare providers need to give patients who don’t have insurance or who are not using insurance an estimate of the bill for medical items and services.
You have the right to receive a Good Faith Estimate (GFE) for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your healthcare provider gives you a Good Faith Estimate in writing at least one (1) business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
If you receive a bill that is at least $400 more than your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate. You may need it if you are billed a higher amount.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
It is not possible for a mental health therapist to know, in advance, how many sessions may be necessary or appropriate for a given client. Therefore, the GFE cost estimate is only an estimate; it isn’t an offer or contract for services, nor does it obligate you to receive services with our practice.
The frequency, length, and cost of treatment can be determined in collaboration with your therapist, in line with your clinical needs and appropriate course of treatment. Please be aware that costs may change as treatment needs change, or services are added or ended, and that you have the right to decide when you wish to end treatment at any time.
The Good Faith Estimate shows the costs of items and services that are reasonably expected for your healthcare needs for an item or service. The estimate is based on information known at the time the estimate was created.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.
In addition, the GFE does not include non-clinical services that you as the client can control in terms of limiting costs that occur outside of therapy appointments, such as: missed appointments/late cancellations, response to subpoenas, legal/court fees, requests for documentation, and/or phone calls or email replies. These are omitted from the GFE as they are not typical services, and they are not eligible for reimbursement from insurance.
GFEs will be reassessed at least once per year, and clients will be given advance notice of any fee changes due to modifications or additions in mental health services at least one (1) day prior to the service appointment.
If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill.
You may contact the healthcare provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.
You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.
There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the healthcare provider or facility, you will have to pay the higher amount.
To learn more and get a form to start the process, go to www.cms.gov/nosurprises or call 1-800-985-3059.
For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or call 1-800-985-3059.
- For more information about your rights under Virginia state law, visit Virginia State Disclosure Notice Protections Against Surprise Billing
- For more information about your rights under Federal law, visit No Surprises Act of the 2021 Consolidated Appropriations Act
- Requirements Related to Surprise Billing; Part II Interim Final Rule with Comment Period
Federal law and regulation information is valid as of 01/01/2022 and subject to change.
HIPAA Notice of Privacy Practices
Notice Of Privacy Practices to Protect The Privacy Of Your Health Information
You have the right to:
- Get a copy of your paper medical record
- Correct your paper or medical record
- Request confidential communication
- Ask us to limit the information we share
- Get a list of those with whom we’ve shared your information
- Get a copy of this privacy notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
You have some choices in the way that we use and share information as we:
- Tell family and friends about your condition
- Provide disaster relief
- Provide mental health care
Our Uses and Disclosures
We may use and share your information as we:
- Treat you
- Run our organization
- Bill for your services
- Help with public health and safety issues
- Do research
- Comply with the law
- Address workers’ compensation, law enforcement, and other government requests
- Respond to lawsuits and legal actions
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get a paper copy of your medical record
- You can ask to see or get a paper copy of your medical record and other health information we have about you. Ask us how to do this.
- We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
- You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
- We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
- You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
- We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
- You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
- If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information
Get a list of those with whom we’ve shared information
- You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
- We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
- You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
- If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
- We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
- You can complain if you feel we have violated your rights by contacting us using the information on page 1.
- You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877- 696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
- We will not retaliate against you for filing a complaint.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care
- Share information in a disaster relief situation
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
How do we typically use or share your health information?
- We typically use or share your health information in the following ways.
- We can use your health information and share it with other professionals who are treating you.
- Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Run our organization
- We can use and share your health information to run our practice, improve your care, and contact you when necessary.
- Example: We use health information about you to manage your treatment and services.
How else can we use or share your health information?
- We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:
Help with public health and safety issues
- We can share health information about you for certain situations such as:
- Preventing disease
- Reporting suspected abuse, neglect, or domestic violence
- Preventing or reducing a serious threat to anyone’s health or safety
Comply with the law
- We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
Address workers’ compensation, law enforcement, and other government requests
- We can use or share health information about you:
For workers’ compensation claims
- For law enforcement purposes or with a law enforcement official
- With health oversight agencies for activities authorized by law
- For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
- We can share health information about you in response to a court or administrative order, or in response to a subpoena. Our Responsibilities:
- We are required by law to maintain the privacy and security of your protected health information.
- We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
- We must follow the duties and privacy practices described in this notice and give you a copy of it.
- We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
- For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
- We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other Instructions for Notice
- The HIPAA Privacy Rule (45 CFR Parts 160-164) requires that HIPAA covered entities provide clients information detailing how their protected health information* will be used or disclosed. This is done through the familiar HIPAA Notice of Privacy Practices (NPP), which outlines client rights and the legal duties of the HIPAA covered entity. The practitioner may not use or disclose protected health information in a manner that is inconsistent with the NPP.
- Therapy records are maintained for a period of 6 years from termination. In the case of a minor child records shall be maintained for six years after attaining the age of majority (18) or ten years following termination, whichever comes later.
- We may use or disclose your protected health information* (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:
- Protected health information is “Individually identifiable health information, including demographic data, that relates to: 1) the individual’s past, present or future physical or mental health or condition, 2) the provision of health care to the individual, or 3) the past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual” (45 C.F.R. §160.103)
- Treatment is when we provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when we consult with another health care provider, such as your family physician or another psychologist.
- Payment is when we obtain reimbursement for your healthcare. Examples of payment are when we disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
- Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations are quality assessment and improvement activities, business related matters such as audits and administrative services, and case management and care coordination.
Effective Date, Name and Contact details of Privacy Official
- This notice went into effect April 14, 2003. Revised December 2014, Revised November 2017 and Revised May 2018.
- Privacy Official: Robyn E. Brickel, MA., LMFT, 300 N. Washington Street, Suite 500; Alexandria, VA 22314, Office: (703) 518-8883,
Email: firstname.lastname@example.org Website: www.brickelandassociates.com
- I have received a copy of the Notice of Privacy Practices and I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Privacy Rule (45 CFR Parts 160- 164) requires that HIPAA covered entities provide clients with information detailing how their protected health information* will be used or disclosed.
- I understand my rights, my choices and how therapeutic and medical information about me may be used and disclosed by Brickel & Associates, and how I can get access to this information. I understand that I may revoke this consent in writing at any time, except to the extent that Brickel & Associates, LLC has taken action relying on this consent.
Brickel and Associates, LLC is committed to providing the best care to all clients, without the intrusion of a third-party dictating service requirements. Therefore, we are a private pay, fee-for-service, out-of-network (OON) practice and we do not participate as a provider with any insurance company.
Prior to the start of any service, all fees will be made clear and agreed upon on our Financial Agreement form, and on a Good Faith Estimate form.
Payment is expected, from client or responsible party, at the time services are rendered, and payment may be made by cash or check.
Payment by cash: If a cash payment is made to the therapist at the time of service, a receipt will be provided.
Payment by personal check: If a payment via check is made, the check should be made out to Brickel & Associates, LLC and given to the therapist at the time of service. A returned check fee of $25 will be charged for all returned checks. If a returned check is received on the account, the client will no longer be allowed to use personal checks as payment. Alternatively, the client may use cash or cashier’s checks as payment for services.
If you are unable to keep an appointment, please notify the therapist immediately. You MUST notify the therapist two (2) business days (i.e., Monday through Friday) prior to scheduled appointment date/time. If an appointment is canceled or missed without two (2) business days notice, you will be billed the session fees for the time you have reserved.
Payment of your bill, including any cancellation fees incurred, is a legal obligation and will be collected accordingly.
We do not participate with any health care/insurance plans. Therefore, if you would like to personally submit claims to your insurance company to use your out-of-network benefits, you may do so. We are aware that some insurance plans and policies, such as Medicare, do not accept out-of-network claims. Since we are not a Medicare provider, you must pay for any services out-of-pocket and will have to sign an agreement stating that you will not seek reimbursement.
If you are eligible to submit a claim for reimbursement, the therapist will provide a statement of receipt, which includes the necessary diagnostic information you will need to submit your claims, to you (the client). Whatever financial benefit the insurance company pays to you is your benefit.
Please note: Practice fees are based on clinician expertise, education, and experience. Because we employ practitioners with varying degrees and certifications, educational backgrounds, and years of experience, we have variability in fees. You are welcome to call our office at 703-518-8883 to learn more about the appropriate therapist fit for your needs, and the rates you can expect.
Practice fees are subject to an annual increase (on or about Jan 1st); however, notification of not less than 30 (thirty) days will be displayed in a conspicuous location in the office and given to all existing clients.
We do not provide therapy services as part of worker’s compensation claims. Please contact your referring doctor or worker’s compensation plan administrator for additional assistance.