Must Have Paperwork For Your Mental Health Private Practice?
With every job there seems to be more paperwork involved than necessary and for mental health professionals that is definitely true when it comes to client documentations and insurance paperwork. Are you wondering if you have the right documentation practices in place and more importantly, if you are doing them correctly? Today we are going to discuss the essential paperwork for your practice in order to ensure compliance with your state board and HIPAA, protect yourself and your business and maintain transparency with your clients.
Let’s dive right into it. Below are the necessary paperwork items you need for your mental health private practice.
A document outlining your practice policies, expectations and practices. If your current informed consent is only one page, that isn’t long enough. Check with your board on the exact must haves for your specific state and license. Some of the most common items you will need are: limits to counselor/client confidentiality, benefits and risks to counseling, practices around medical records, fees, electronic communication, appointments and cancellation policy, phone contact and emergencies, structure of therapy, and dual relationships.
Check out Kate and Katies video on the 13 must haves.
This can be rolled into your informed consent, but I prefer to have a separate document for agreeing to the fees associated with therapy. We’ve all got money issues and either brush over it or don’t mention it at all but we need to be setting firm limits and expectations for our clients and holding true to those (so if you’ve agreed on a fee for a session, charge that fee at the beginning of every session, hold true to your agreement). This form should state your professional fee for services (all services), as well as cancellation charges, policy for if payment was not accepted, authorization to charge card on file, etc.
Release of Information (ROI)
So you can talk with your clients current and past providers in order to collaborate and do the best work possible for your clients. Remember to get a ROI signed to talk with ANYONE other than your client and to keep them up to date when they expire.
Paperwork that you want your client to complete prior to the first session with you. Can include: Demographic information, Relevant history gathering, Relationship information, Clinical information, Preferred contact method, etc.
This is typically only used if you are an out-of-network provider with someone's insurance company and they are wanting to file for possible reimbursement. Typically provided to client on a monthly basis so they can file it with their insurance company. Most EHR platforms will generate this automatically for you but if you are creating your own it needs to have the following: your practice name, address, contact information, NPI #, License #, and Tax ID #, Clients name, address, contact information and DOB, Diagnosis Code, Date of services, service code, description of services and total amount paid to you for services
*Connect your clients with Get Better to assist them in getting reimbursed for services they have paid out of pocket for.
Invoice/Receipt for Services
*All paperwork should be looked over and approved by a business attorney*
At b.mindful Louisville we provide each tenant with full access to our practice building resources. Within the paperwork section we provide detailed information for what needs to be in your informed consent, templates you can alter for your financial agreement, HIPAA statement, ROI, superbill, intake paperwork, scripts and more.