Am I Ready To Hang My Mental Health Practice Shingle?

Posted by donna@healthlawcenterplc.com in Jan, 2021

Frequently mental health professionals request a review of a policy and procedure or a consent forms, etc. when either forming a new practice or to determine if the existing practice’s documents are legally sufficient.  Whether a new mental health practice or an existing practice, it is important that the business structure, which includes the practice’s documents and policies and procedures, be comprehensive and documents interface with each other and adhere to federal and state law.  Determining whether a consent form alone is legally sound is not sufficient.  The following serves as a minimum checklist the practice should consider in forming and maintaining a mental health practice in order to comply with state and federal laws.

HIPAA Requirements – 

       Written Documents —

• HIPAA Compliant Authorization for the Release of Information
• Consent to Treatment
• Protected Health Information Policy
• HIPAA Required Business Associate Agreements between healthcare professional and vendors, such as electronic medical record vendors, billing companies, legal services, etc.
• Notice of Privacy Practices (“NPP”)
• Acknowledgment of Receipt of NPP
• As applicable, HIPAA Compliant Policies and Procedures to Ensure the Integrity, Confidentiality and Availability of Client Protected Health Information (“PHI”)
• PHI Breach Notification Policy and Procedure
• Maintaining Psychotherapy Notes Consistent with HIPAA
• Consent for Telehealth Services
• Policy and Procedure in Releasing Client PHI

HIPAA Compliance —

• As Applicable, Conduct HIPAA Security Risk Analysis and Assessment and Implement Practice Physical, Administrative and Technical Safeguards
• Identification of Privacy Officer and Security Officer
• Conduct HIPAA Training for the Workforce, Consistent with HIPAA Requirements

Written Business Documents

• Office Space Lease / Time Share Arrangements
• Employment Contracts
• Independent Contractor Agreements
• Electronic Health Record Vendor Contracts
• Billing Company Vendor Contracts
• Client Intake Form
• Supervision Contracts for Limited Licensed Professionals

Written Practice Policies and Procedures

• Response to Subpoenas and Requests for Client PHI
• Providing Services to Minors
• Office Practices, Including Payment Expectations, Cancellation of Appointments, No Shows, etc.

These documents and compliance steps are the minimum considerations in forming and maintaining a mental health practice.  Obviously the bigger the practice the more defined written policies and procedures are needed to ensure all therapists are practicing consistently with practice requirements and written policies and procedures.  For any questions or more information, feel free to contact Donna J. Craig, Nurse/Attorney at The Health Law Center (donna@healthlawcenterplc.com).