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Patient Information

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Terms and Policy

Billing Costs/Policies

Danielle Lew, Trinity Wellness Services, LLC has hired an independent billing agency that will submit insurance claims to your insurance company. The company used for billing is Elite Billing Corporation (229 N. Liberty St Suite A. Centreville, MD 21617) Phone; 410-684-3961.

Secondary insurance will NOT be billed unless you are 65 years of age or are receiving Medicare benefits.

It is YOUR responsibility to understand your insurance.

Should you abruptly terminate, discontinue, drop out, or are discharged from treatment and you still have a balance on your account, we will attempt to contact you via a paper bill three times.

Should you choose not to respond to these bills, we will turn your account over to a Collections Agency and/or an Attorney (demographic data collection only). You will be responsible for the balance due, all applicable finance charges, and all third party collection company fees and/or attorney's fees up to an additional 50% of the total balance outstanding. In addition to these fees, you will pay all court costs, filing fees, and processing fees. If collection proceedings begin on your account, you will no longer be followed by Danielle Lew.

All charges must be paid in full within 30 days of the billing invoice. Administrative fees and co-pays for treatment services are not covered by insurance and are your responsibility.

Fee Schedule is set as follows & CO-PAYMENTS and DEDUCTIBLES are due at the time of the appointment. All services are billed at a per session rate. A regular session is approximately 50 minutes.

Initial Assessment $150

Family Therapy $120
Individual Therapy $110

Group Therapy $40-$75; per person per group
70-85 minute session $150

Phone calls that are 15 minutes or longer will be billed on the quarter hour of the $110 rate.

If you request a letter for an employers, medical providers, disability forms, etc. There will be a $25-$50 fee depending on time form requires. 

MISSED APPOINTMENT. If you do not call therapist to notify (a "No call No Show"), you will be charged full session fee as outlined above.

Under each circumstances, your credit card on file will be charged the same day of the missed appointment.  

Your insurance company will not cover these costs so it will be a direct cost to you. Please be mindful that your appointment time is scheduled for you and only you! Unexpected emergencies and sickness' are understandable, and a different matter entirely. Missed appointments are disruptive to the therapeutic process and may be grounds for termination of treatment.

*Two consecutive late cancellations of appointments may result in termination of treatment by Danielle Lew, Trinity Wellness Services, LLC. If you insurance company will cover the cost of teletherapy, and you have access to a mobile device or computer to see therapist in this way vs physically going to the office, the late charge will not apply.

*Checks that are not honored by your financial institution and returned will be redeposited once. A fee of $50 will be assessed to your account each time a check is returned.

*All referrals from Primary Care Doctors, pre authorization from insurance companies, managed care organizations, or HMO's must be obtained prior to the first scheduled appointment. Some organizations allow our office to obtain the authorization for the first visit; others insist that the patient call personally.

*Any professional at Danielle Lew, Trinity Wellness Services, LLC reserves the right to cancel an appointment at any time if the necessary authorization is not obtained, unless the patient agrees to pay the full fee for the visit.

*Preauthorization is not a guarantee of payment. Danielle Lew, Trinity Wellness Services, LLC cannot and will not guarantee that your insurance company will pay for your treatment. If you have any questions about your insurance plan, it is your responsibility to contact them.

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In event of legal proceeding
In event of a Legal Proceeding (I do NOT wish to get called into court- however, if I am, these are the policies):

There is thirty-two cents ($0.32) per page and a sixteen dollar ($16) retrieval fee attached to accounts for forwarding records to another provider for coordination of care or to an attorney. Should you require that any professional at Danielle Lew, Trinity Wellness Services, LLC appear in any legal proceeding (including, but not limited to, appearance in court, deposition, or administrative proceeding) via a subpoena or summons, or if asked to attend any meetings of a legal nature, the following fees shall be charged:

a) Meeting with counsel in our office- $110.00 due prior to the meeting for a one-hour meeting, then $110.00 per hour to cover therapist time and paperwork after the completion of the meeting;
b) Meeting with counsel outside of our office-- $250.00 due prior to the meeting (if in York county) for a one-hour meeting ($350.00 due prior to the meeting for a one-hour meeting in Carroll or Baltimore County) then $110.00 per hour to cover therapist time and paperwork after the completion of the meeting.
c) Appearance at deposition, court, or administrative proceeding (whether called by your attorney or any other party's attorney) -
$500.00 for any appearance up to three hours in duration due prior to appearance; $750.00 for any appearance lasting from three to five hours; $1,000.00 for any appearance lasting five to seven hours. Note: Time spent travelling to and from any appearance at a deposition, court, or administrative proceeding will count towards the appearance fee. For example, two hours of travel time will be added to a two hour deposition or court appearance in York and will result in a charge of $750.00.

Note: These additional meetings and judicial/administrative proceedings are not covered by your insurance , are very time consuming, and keep our professionals from seeing other patients. It is your responsibility to work with your attorney to minimize our time involved in judicial/administrative proceedings. Due to our need to schedule patients around judicial/administrative proceedings, the full fee shall be owed unless notice of cancellation is received at least seven (7) business days in advance of the scheduled appearance.
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Rights and Responsibilities

Please read this information carefully. It will inform you about what you can expect from our office as well as your responsibilities.
As a patient of Danielle Lew, Trinity Wellness Services, LLC you have the right to:

1. Be provided care and treatment with dignity and respect.
2. Receive impartial services and access to treatment regardless of race, religion, gender, sexual orientation, ethnicity, age, disability, or
source of payment.
3. Have an individualized treatment plan and to participate in its development and treatment planning decisions.
4. Inquire as to training, credentials, and professional status of any professional providing services to you at Danielle Lew Trinity Wellness
Services, LLC.
5. Discontinue treatment at any time. It is preferred that you discuss this decision with your therapist at Danielle Lew, Trinity Wellness
Services, LLC and not abruptly stop treatment.
6. Refuse treatment and to be informed of the consequences of refusal.
7. Be free from physical, sexual, or mental abuse.
8. Obtain services in a safe environment. No patient shall ever bring with them to the office any type of weapon or dangerous item.
9. Have policies, procedures, fees and charges clearly explained. Patients may ask at any time if they do not understand something in
regards to these items.
10. Tell your therapist if you are not satisfied with your care.
11. Have access to the medical and psychological data in your clinical record in accordance with federal and state law within a reasonable
time, but no more than 21 working days after the date of the request. If access is denied, you have the right to a written summary.
Copies of records are provided at a cost to you. The current cost is $0.35 per page. Information will be provided to other health care
professionals with a written release free of charge.
12. Danielle Lew, Trinity Wellness Group, LLC will do all the necessary paperwork required by your insurance company so as to obtain
reimbursement for services and additional authorizations for services needed.

13. You have the right to refuse treatment with Trinity Wellness Group, LLC (for whatever the reason)- if you communicate this, we will provide you with alternative options of treatment.

As a patient of Danielle Lew, Trinity Wellness Services, LLC you have the responsibility to:

1. Be on time for your appointment or give a 24 hour notice of cancellation.
2. Provide information to Danielle Lew, Trinity Wellness Services, LLC as needed so that the appropriate care can be rendered. This
includes changes in insurance carriers as well as demographic information.
3. Participate in the development of treatment plan goals with Danielle Lew, Trinity Wellness Services, LLC.
4. Treat your therapist and all staff at Danielle Lew, Trinity Wellness Services, LLC & Associates with the same respect and kindness you
expect to receive.
5. Take medications as instructed by your doctor.
6. Discuss with your therapist Danielle Lew, Trinity Wellness Services, LLC any dissatisfaction you have with any services provided or
encounters you may have with Danielle Lew, Trinity Wellness Services, LLC .
7. Read all materials given to you and ask questions if you don't understand.
8. Obtain all necessary referrals and authorizations from your primary care doctor/insurance carrier.
9. Maintain confidentiality about other patients that you may see in the office.

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Notice of HIPPA Privacy Policies
Notice of HIPAA Privacy Policies for Danielle Lew, Trinity Wellness Services, LLC

ACCESS TO THIS INFORMATION. Please review it carefully.

Danielle Lew, Trinity Wellness Services, LLC is committed to treating and using protected health information about you responsibly. Practice describes the personal information I collect, and how and when I use or disclose that information. It also describes your rights as they relate to your protected health information. This NOTICE is effective immediately and applies to all protected health information as defined by federal regulations.


Each time you visit Danielle Lew, Trinity Wellness Services, LLC, a record of your visit is made. Typically, this record contains your symptoms, diagnosis, and plan for future care. This information, often referred to as your medical record serves as a:

- Basis for planning your care and treatment.
- Means of communication among the many health professionals who contribute to your care.
- Legal documents describing the care you received.
- Means by which you or a third-party payer can verify that services were actually provided.
- A tool in educating health professionals.
- A source of data for planning and marketing.
- A tool with which I can assess and continually work to improve the care I render and the outcome we achieve.

Understanding what is in your record and how your health information is used helps you to ensure accuracy, better understand who, what, when, where and why others may access your health information, and make more informed decisions when authorizing disclosures to others. An EMR is utilized to maintain records. It is a HIPAA Compliant website at that it password protected
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Limits of Confidentiality

The following exceptions for confidentiality are to be noted and observed:

1. Duty to Warn and protect
When a client discloses intentions or a plan to harm another person, Trinity Wellness Group, LLC is required to warn the intended victim and report the information to legal authorities. In cases in which the client discloses or implies a plan for suicide, the Trinity Wellness Group, LLC is required to notify legal authorities and make reasonable attempts to notify the family of the client

2. Abuse of Children or Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult) or a child (or vulnerable adult) is in danger of abuse, Trinity Welless Group, LLC is required to report this information to the appropriate social service and/or legal authorities.

3. Prenatal Exposure to Controlled Substances
Trinity Wellness Group, LLC is required to report admitted prenatal exposure to controlled substances that are potentially harmful.

4. Insurance Providers (when applicable)
Information that may be requested includes, but is not limited to: types of service, dates/times of service, diagnosis, treatment plan, description of impairment, progress of therapy, case notes, and summaries.

5. Court Orders & Legal Issued Subpeonas: If your therapist receives a subpoena for your records, they will contact you so you may take whatever steps you deem necessary to prevent the release of your confidential information. Your therapist will contact you twice by phone and send you an email or letter (if they cannot get in touch with you by phone). If a court of law issues a legitimate court order, your therapist is required by law to provide the information specifically described in the order. Despite any attempts to contact you and keep your records confidential, your therapist is required to comply with the court order.

6. Fee Disputes: In the case of a credit card despite, Trinity Wellness Group, LLC reserves the right to provide the needed and adequate documentation.

7. Dual Relationships & Public: Your relationship with y our therapist is strictly professional. In order to preserve this relationship, it is imperative that you do not have any relationship outside the counseling relationship such as friendship, business, or social relationship. If you do have contact with your therapist in a public setting, they will not acknowledge you in any way that would jeopardize your confidentiality. Should you choose to acknowledge your therapist, they may not be able to protect your confidentiality.

Danielle Lew, Trinity Wellness Services, LLC will not use or disclose your health information without your written authorization, except as described above. Danielle Lew, Trinity Wellness Services, LLC will also discontinue the use of, or disclosure of, your health information after receipt of a written revocation of authorization according to the procedures included in the authorization.

You will be asked to sign below verifying that you have received this information according to HIPAA regulations.

( Type Full Name )
Consent of Agreement

Trinity Wellness Group, LLC will retain a copy of this signed page as part of your medical record and reference. Your signature date indicates that you are in agreement with our policies. In case of significant changes, you will be asked to review and sign a new policy agreement.

Your signature below indicates that you are providing your informed consent to participate in behavioral health services provided by Trinity Wellness Group, LLC. You agree to hold harmless and release all liability Trinity Wellness Group, LLC providers and staff for any negative effects or damages that may result from your participation in said services, release of information, and/or fee collection process.

Benefits/Outcomes- Participating in therapy can result in numerous benefits, including improving interpersonal and intrapersonal relationships, as well as resolving the concerns that led you to therapy. Therapy will seek to meet goals established by all persons involved, usually revolving around a specific complaint(s). A major benefit that may be gained from therapy includes a reduction in distress and a better ability to handle or cope with personal, relational, family, work, and other problems as well as stress. Another possible benefit may be a great understanding of personal and relational goals and values; this may lead to greater maturity and happiness as an individual and increased relational harmony. Other benefits relate to the probably outcomes resulting from resolved specific issues that brought you into therapy. Your therapist will do their best to assess progress on a regular basis & solicit feedback regarding the therapeutic process to help you with the most effective therapeutic services. We can make no guarantees as to the ultimate outcome of therapy.

Expectations: Work outside of the counseling sessions is an essential aspect of change. Your therapist may assign tasks between sessions related to your goals. Our commitment is to work as efficiently as possible, but at the same time, therapy may move more slowly than you anticipated. We will collaborate to identify your therapeutic goals and will periodically review your progress toward them.

Risks: In working to achieve these potential benefits, the therapeutic process requires that actions be made to change and may involve experiencing discomfort. Therapeutically resolving unpleasant events and relationship patterns may arouse intense, unexpected feelings. Seeking to resolve problems can similarly lead to discomfort as well as relational changes that may not be originally intended. We will work together for a desirable outcome; however, there is a possibility that the goals of therapy will not be met. We will review your progress at regular intervals and modify your treatment plan as needed.

I understand that Trinity Wellness Group, LLC has a safety surveillance camera located in the waiting area of the office. This camera is for safety purposes only and will only be saved if there was a violation of safety or damage done in the office in which the recording would be turned over to police for investigation. I am signing this agreement that I was made aware that the camera exists and the purposes of the camera.

You are in agreement that you, or anyone on your behalf, file a lawsuit, licensure, or ethics complaint, or take any other part legal action against Trinity Wellness Group, LLC concerning any aspect of your participation in services, and there is a favorable ruling for Trinity Wellness Group, LLC and/or employees of Trinity Wellness Group, LLC, you will be responsible for all legal, professional, office, and court costs for the complaint or suit filed by you or anyone on your behalf. These costs will be due 30 days from the determination in favor of the Trinity Wellness Group, LLC.

When you sign this Agreement, you are indicating that you have read, understand, and agree to the terms of the Agreement, as well as the policies outlined above.

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Electronic Communication Policy
Electronic Communication Policy

In order to maintain clarity regarding our use of electronic modes of communication during your treatment, I have prepared the following policy. This is because the use of various types of electronic communications is common in our society, and many individuals believe this is the preferred method of communication with others, whether their relationships are social or professional. Many of these common modes of communication, however, put your privacy at risk and can be inconsistent with the law and with the standards of my profession. Consequently, this policy has been prepared to assure the security and confidentiality of your treatment and to assure that it is consistent with ethics and the law. If you have any questions about this policy, please feel free to discuss this with me.

Email Communications
I use email communication and text messaging only with your permission and only for administrative purposes unless we have made another agreement. That means that email exchanges and text messages with my office should be limited to things like setting and changing appointments, billing matters and other related issues. Please do not email me about clinical matters because email is not a secure way to contact me. If you need to discuss a clinical matter with me, please feel free to call me so we can discuss it on the phone or wait so we can discuss it during your therapy session. The telephone or face-to-face context is a much more secure as a mode of communication. Please be advised that if you are emailing from a work email, your employer has the right to read your emails. Additionally, emails are a part of your medical record.

Text Messaging
Text messaging is a very unsecure and impersonal mode of communication, however it can be a convenient way to communicate. If you chose to text me regarding questions about your appointment times, cancellations, etc, that is acceptable. However, please limit your texts to these specific circumstances and do not text anything personal or anything specific related to your treatment.

Social Media
I do not communicate with, or contact, any of my clients through social media platforms like Twitter and Facebook. In addition, if I discover that I have accidentally established an online relationship with you, I will cancel that relationship. This is because these types of casual social contacts can create confidentiality risks for you.

I do participate on various social networks. If you have an online presence, there is a possibility that you may encounter me by accident. If that occurs, please discuss it with me during our time together. In addition, please do not try to contact me in this way. I will not respond and will terminate any online contact no matter how accidental.


I have a website that you are free to access. I use it for professional reasons to provide information to others about me and my practice. You are welcome to access and review the information that I have on my website and, if you have questions about it, we should discuss this during your therapy sessions.

Web Searches
I will not use web searches to gather information about you without your permission. I believe that this violates your privacy rights; however, I understand that you might choose to gather information about me in this way. In this day and age there is an incredible amount of information available about individuals on the internet, much of which may actually be known to that person and some of which may be inaccurate or unknown. If you encounter any information about me through web searches, or in any other fashion for that matter, please discuss this with me during our time together so that we can deal with it and its potential impact on your treatment.
Recently it has become fashionable for clients to review their health care provider on various websites. Unfortunately, mental health professionals cannot respond to such comments and related errors because of confidentiality restrictions. If you encounter such reviews of me or any professional with whom you are working, please share it with me so we can discuss it and its potential impact on your therapy. Please do not rate my work with you while we are in treatment together on any of these websites. This is because it has a significant potential to damage our ability to work together.
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