Blue Square
47294 Progress Court, Suite C      Soldotna, Alaska (in the new Redoubt Realty location)      Phone: (907) 262-4470      Fax: (888) 375-4966
Blue Square

Northern Psychology Resources in Alaska
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Fireweed
Financial Policy

Insurance Claims
Northern Psychology Resources, LLC accepts most insurance including Denali Kid care and Medicaid; we will bill on the behalf of our clients as a courtesy.  This in no way alleviates the financial responsibility of the individual accepting services or their responsible party. Please bring insurance information to your first appointment. Please contact your insurance company for preapproval and to ensure that services are covered by your policy. We are happy to assist with preauthorization.

Financial Policy
I, the undersigned, understand that I am financially responsible for all services rendered at Northern Psychology Resources, LLC for myself and my dependants. I request that NPR file my insurance claims, when applicable, on my behalf. I understand that my insurance company may not cover all costs related to my services and I am responsible, at the time of service, for any co-pays, deductibles, and non covered expenses.  I agree to pay my portion at each visit unless PRIOR arrangements have been made.  If payment has not been received from my insurance company within 45 days I understand that the balance of the account becomes my responsibility and is due immediately.  There will be a $35.00 NSF charge for all returned checks.  If a check is returned and payment is not secured immediately the account will be sent to collections. Payment may be made with CASH, Check, or Visa/MasterCard Credit Cards.

Past Due Accounts
All accounts that have a balance after 45 days will be assessed a finance charge of 1.5% per month.  If the account is not paid in full within 120 days, or acceptable arrangements have not been made in writing with our office, the account will be sent to a collection agency. I will be responsible for any and all additional fees associated with collections. No further services will be rendered until the account is paid in full, and any services requested after such time will be on a cash-only basis.

Signature on File
I authorize the release of any necessary information, including any treatment records or summaries, to my insurance company or a consulting professional in order to secure payment on my behalf.  The information released to my insurance company is solely for the purpose of obtaining financial reimbursement directly to Northern Psychology Resources, LLC; and Dr. Jacqueline Bock, PhD.  I request and authorize my insurance company to pay Northern Psychology Resources, LLC directly for all services rendered.  I authorize the use of the signature on this page on all insurance submissions.  I also authorize the release of any information necessary to consult with other professionals regarding current and continuing treatment, and in the event of a referral to another provider of service.

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HIPPA Privacy Policy
HIPPA Privacy Policy

Notice of Privacy Practices
Effective september 20, 2013

This Notice Describes How Medical Information About You May Be Used and Disclosed and How You Can Get AcCESS To This Information. 
Please Review It Carefully.

This Notice describes the medical information practices of Northern Psychology Resources, LLC, office of Dr. Jacqueline Bock, PhD.  Northern Psychology Resources, LLC is considered a covered entity, and therefore we are required by law to maintain the privacy of personal health information and to provide you with notice of our legal duties and privacy practices with respect to personal health information.  All of Northern Psychology Resources, LLC, departments, providers and employees are covered by this Notice and your personal health information may be shared among these divisions. 

Our Pledge Regarding Medical Information

We understand that medical information about your health is personal.  We will not disclose your personal health information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.  This Notice applies to all of the medical records we maintain. It describes the ways in which we may use and disclose medical information, and describes our obligations with regard to such information.  .

We are required by law to:
• Keep your protected health information private;
• Provide notice of our legal duties and privacy practices with respect to protected health information;
• Notify affected individuals following a breach of unsecured protected health information;
• Give you this Notice of Privacy Practices;  and
• Follow the terms of the Notice of Privacy Practices currently in effect.

We have the right to change our practices regarding the personal health information we maintain.  If we make changes, we will update this Notice.  You may receive the most recent copy of the Notice by calling the Privacy Officer at 907-262-4470, or stopping by the Privacy Officer’s office at 176 North Birch Street, Soldotna, AK 99669 (the “Privacy Officer”).

How We May Use/Disclose Your Medical Information

The following are some of the different ways that we may use and disclose your personal health information:

For Treatment.  We may use or disclose medical information about you to facilitate treatment, rehabilitation or treatment through services provided by Dr. Jacqueline Bock, PhD.  For example, we may disclose medical information to other healthcare providers who are involved in taking care of you.

For Payment.  We may use and disclose medical information about you to get reimbursed for the services we provide to you, including such things as submitting bills to insurance companies (either directly or through a third party billing company), medical necessity determinations and reviews, and collection of outstanding accounts.

For Health Care Operations.  We may use and disclose medical information about you for other Northern Psychology Resources, LLC health care operations as necessary.  For example, we may use medical information in connection with: conducting quality assessment and improvement activities; licensing; personnel training programs; fraud and abuse detection programs; and general administrative activities.

To Business Associates.  There are some services provided to Northern Psychology Resources, LLC through contracts with business associates.  Examples include accounting, legal, training, and consulting services.  Information shall be made available to business associates consistent with their need to know for purposes of providing services.

Health Oversight Activities.  We may disclose medical information to a health oversight agency for activities authorized by law.  These oversight activities include, for example, audits, investigations, inspections, and licensure. 

As Required by Law.  We will disclose medical information about you when required to do so by federal, state or local law.  For example, we may disclose medical information when required by a court order.

To Avert a Serious Threat to Health or Safety.  We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of another person.  Any disclosure, however, would only be to someone able to help prevent the threat. 

Other Uses and Disclosures
We may also use and disclose your health information in the following circumstances, when permitted by law, and with only the minimum necessary information being disclosed:

• Appointment reminders
• Language interpreters
• Information about available treatments or products
• Funeral Directors/Coroners/State Medical Examiners
• Workers’ Compensation
• Correctional Institutions (if you are in jail or prison)
• Law Enforcement
• Tissue and organ donation
• Disaster relief
• Military and Veterans (if you are an armed forces member)
• Responses to legally compliant court orders
• National security

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization.  This includes the use or disclosure of psychotherapy notes, the use or disclosure of PHI for marketing, or the sale of PHI, which will require your express written authorization.

Your Rights Regarding Personal Health Information
You have the following rights regarding medical information we maintain about you:

  • Right to Inspect and Copy.  You may come to our offices and request a copy most of the medical information about you that we maintain.  We will normally provide you with access to, or copies of, this information within 30 days of your request.  Due to the nature of our relationship with clients and the sensitive nature of the records that we keep, we do not keep records electronically and do not make records available electronically or through email.  In limited circumstances, we may deny you access to your medical information, and you may appeal certain types of denials. 
  • Right to Amend.  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  To request an amendment, your request must provide a supporting reason, be made in writing, and be submitted to the Privacy Officer.  If we agree to amend the information, we will generally amend your information within 60 days of your request and will notify you when we have amended the information

We may deny your request for an amendment if does not meet the criteria for amendment. In addition, we may deny your request if you ask us to amend information that: is not kept by or for Northern Psychology Resources, LLC; was not created by us, unless the person or entity that created the information is no longer available to make the amendment; is not part of the information which you would be permitted to inspect and copy; or is accurate and complete.

  • Right to an Accounting of Disclosures.  You have the right to request a list of disclosures, where such disclosure was made for any purpose other than treatment, payment or health care operations.  We are not required to give you an accounting of information we have shared with our business associates or for which you have given us a written authorization.

To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer.  Your request must state a time period, which may not be longer than six years or before April 14, 2003.  Your request should indicate in what form you want the list (i.e. paper or electronic).  The first list you request within a 12-month period will be free, and you may be charged for the cost of any additional lists.  We will notify you of the cost and you may choose to withdraw or modify your request before any costs are incurred.

  • Right to Request Restrictions.  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations.  You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not use or disclose information about a transport or treatment we provided.  We are not required to agree to your request unless the disclosure is to a health plan for purposes of carrying out payment or health care operations (not treatment purposes) and the information pertains solely to an item or service paid for fully out of pocket.

To request restrictions, you must make your request in writing to the Privacy Officer.  In your request, you must describe: (1) what information you want to limit; (2) whether you want to limit use, disclosure or both; and (3) to whom the limits shall apply, for example, your spouse.

  • Right to Request Confidential Communications.  You can request that we communicate confidentially with you about medical matters.  For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the Privacy Officer.  We will accommodate reasonable requests.  Your request must specify how you wish to be contacted.
  • Right to a Paper Copy of This Notice. You may request a paper copy at any time.  Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy.

Right to Revoke Authorization/Permissions

If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. 

Questions/Exercising Rights

If you have any questions about this Notice or would like to exercise any of the rights contained herein, please contact:  Northern Psychology Resources, LLC Privacy Officer, 176 North Birch Street, Soldotna, AK 99669  907-262-4470.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with Northern Psychology Resources, LLC or with the Secretary of the Department of Health and Human Services.  To file a complaint with Northern Psychology Resources, LLC contact the Privacy Officer.  All complaints must be submitted in writing.  You will not be retaliated against or penalized for filing a complaint. The Secretary of DHHS can be reached at:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue. S.W.
Room 509F, HHH Building
Washington, D.C. 20201
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Blue Square
47294 Progress Court, Suite C      Soldotna, Alaska (in the new Redoubt Realty location)       Phone: (907) 262-4470      Fax: (888) 375-4966
Blue Square
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