I agree and consent to participate in behavioral health services offered and provided by

I understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within the scope of the provider’s license, certification and training. If the patient is under the age of 18 or unable to consent to treatment, I attest that I am authorized to initiate and consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of the individual.

INITIAL EVALUATION & SESSIONS

We generally conduct a thorough psychiatric evaluation during the initial session – which is typically scheduled for 60 minutes. This assessment focuses on determining the best treatment plan possible and is specific to each individual patient. It is extremely important for this initial assessment to be as comprehensive as possible. Therefore, please bring completed patient forms to this appointment and make sure to provide information about previous providers, past psychiatric treatment, and medication trials. In some situations, extra sessions are needed to complete an appropriate evaluation. Additionally, collateral information (i.e., school reports, family reports, etc are often necessary for children and adolescents – and helpful for adult patients as well. These issues will be discussed during the initial session. Please remember that a comprehensive assessment is necessary as it allows us to provide the best possible care.

PRACTICE STATUS

There are other independent providers who sublease office space within the suite. While we share space and often provide collaborative care, each provider is responsible for providing care up to professional standards. All records are stored using an industry leading electronic health record called Practice Fusion. The office manager also may, at times, have access to your record. Please note that it is our policy to always protect this information in accordance with all legal and ethical standards. Additionally, your provider within a network of other professional colleagues (i.e., primary care doctors, other specialty physicians, psychologists, social workers, therapists, nutritionists, etc that we use as referrals for multidisciplinary care. If a referral is necessary, this will be discussed in session and your provider will work to collaborate with these professionals and coordinate your care. Please note, however, that although we attempt to identify top quality professionals with very high standards of care, we cannot be responsible for the services/treatment that they provide. It is always your responsibility to determine if a professional referral is acceptable, and alternative options will be considered.

MEDICATION MANAGEMENT

Psychiatric medications can be used in conjunction with psychotherapy to treat many conditions. It is important to find the best combination of medications and therapy for each individual case. Your nurse practitioner of psychiatry can provide an integrated approach as a nurse practitioner of psychiatry is trained to administer both psychiatric medications and psychotherapy. However, in almost all situations, it will be appropriate to consider only managing your psychiatric medications and sharing the psychotherapy with an alternative provider. We can help find a provider for you in the community. In situations that warrant the use of medications, it is imperative for you to understand the target symptoms and likely outcomes. Additionally, since all medications have the potential for side effects, your nurse practitioner will always discuss the risks, benefits, side effects, government warnings, and alternative treatments (which always includes not using medications) with you.

 

REFILLS

We make every effort to see you before you need a refill.  We need atleast 2 days to refill a medication and reserve the right to refuse to renew a medication if in the provider's opinion, the patient needs to be evaluated before a refill is given.  ALL PATIENTS THAT ARE PRESCRIBED A CONTROLLED SUBSTANCE MUST BE SEEN ON A MONTHLY BASIS. 

Patients that are not seen for more than 3 months are considered to no longer be under the care of the provider.  In such cases, the provider will need to see the individual as a new patient after that time.  

BILLING AND PAYMENTS

I understand that I am expected to pay my copay for each session at the beginning of each appointment. Alternative payment plans must be discussed with and agreed to by your provider.

I understand that payment for ‘other professional services’ such as Legal documentation, Disability, other issues will be billed to the patient at $200 per hour.  I authorize the release of any medical or other information necessary to process insurance claims. I also request payment of benefits to the party who accepts assignment. I authorize payment of medical benefits to Maryann Ryan, NPP for services.

CANCELLATIONS AND NO-SHOW POLICY

Once your appointment is scheduled, you will be expected to pay the full professional fee unless you provide at least 48 business hours advance notice of cancellation. Both telephone and email are acceptable ways to alert us of a cancellation. Please remember that business hours are considered weekdays from Monday through Friday and exclude all standard holidays. Also, insurance companies generally do not reimburse for missed sessions or those cancelled too late

CONTACTING YOUR PROVIDER

We always attempt to be accessible for all urgent issues. If your provider is not immediately available by office telephone (845-545-5444), please leave a voice message and we will return your call as soon as possible. Calls are generally returned within one business day. Please always leave a phone number where you can be best reached. If your call is an emergency, please contact 911 immediately instead of calling the office. Emergency psychiatric services are provided by all hospitals through their emergency rooms and do not require appointments. Emergency room physicians can contact your provider at any time so please provide them with his/her contact information. When your provider is unavailable for extended periods of time (i.e., vacation, conferences, etc, a trusted colleague will provide coverage and contact information will be provided on the office voicemail. Please also note that email OR texts should never be used for urgent or emergency issues. This is not a confidential means of communication and we cannot ensure that email or text messages will be received or responded to in a timely fashion

PROFESSIONAL RECORDS

Both law and professional standards protect mental health records. Although you are entitled to review a copy, these records can be misinterpreted given their professional nature. In rare cases when it is deemed potentially damaging to provide you with the full records directly, we can review them together and/or treatment summaries can be provided.

CONFIDENTIALITY

Confidentiality is a cornerstone of mental health treatment and is protected by the law. Aside from emergency situations, information can only be released about your care with your written permission. If insurance reimbursement is pursued, insurance companies also often require information about diagnosis, treatment, and other important information (as described above) as a condition of your insurance coverage. Several exceptions to confidentiality do exist that actually require disclosure by law: (1) danger to self – if there is threat to harm yourself, we are required to seek hospitalization for the client, or to contact family members or others who can help provide protection; (2) danger to others – if there is threat of serious bodily harm to others, we are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization; (3) grave disability – if due to mental illness, you are unable to meet your basic needs, such as clothing, food, and shelter, we may have to disclose information in order to access services to provide for your basic needs; (4) suspicion of child, elder, or dependent abuse – if there is an indication of abuse to a child, an elderly person, or a disabled person, even if it is about a party other than yourself, we must file a report with the appropriate state right to agency; (5) certain judicial proceedings – if you are involved in judicial proceedings, you have the right to prevent us from providing any information about your treatment. However, in some circumstances in which your emotional condition is an important element, a judge may require testimony through a court order. Although these situations can be rare, we will make every effort to discuss the proceedingswith you accordingly. We also reserve the right to consult with other professionals when appropriate. In these circumstances, your identity will not be revealed and only important clinical information will be discussed. Please note that such consultants are also legally bound to keep this information confidential.

ELECTRONIC MAIL (EMAIL) OR TEXTS

Always be aware that email or text messages are not a confidential means of communication. We cannot guarantee that email messages or text messages will be received or responded to in a timely fashion. As such, email or texts messages is not an appropriate way to communicate confidential or urgent information.

LEGAL TESTIMONY

Legal matters requiring the testimony of a mental health professional can arise. This, however, can be damaging to the relationship between a patient and his/her provider. As such, we generally recommend that you hire an independent forensic mental health professional for such services.

Your signature below indicates that you have read the Treatment Consent Form, which contains information on psychiatric services, sessions, professional fees, cancellation and no-show policies, billing and payments, insurance reimbursement, contacting providers, professional records, confidentiality, and practice status, and you agree to abide by its terms during our professional relationship.

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:
1. This authorization may include disclosure of information relating to ALCOHOL and DRUG TREATMENT, MENTAL HEALTH TREATMENT, and CONFIDENTIAL
HIV/AIDS­RELATED INFORMATION only if I place my initials on the appropriate line in item 8. In the event the health information described below includes any
of these types of information, and I initial the line on the box in Item 8, I specifically authorize release of such information to the person(s) indicated in Item 6.
2. With some exceptions, health information once disclosed may be re­disclosed by the recipient. If I am authorizing the release of HIV/AIDS­related, alcohol or
drug treatment, or mental health treatment information, the recipient is prohibited from re­disclosing such information or using the disclosed information for any
other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of
HIV/AIDS­related information, I may contact the New York State Division of Human Rights at 1­888­392­3644. This agency is responsible for protecting my rights.
3. I have the right to revoke this authorization at any time by writing to the provider listed below in Item 5. I understand that I may revoke this authorization except
to the extent that action has already been taken based on this authorization.
4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be
conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent

The purpose of this disclosure of intoration it to share information relevant to treatment and coordinate treatment services.