Please take the time to carefully read this contract in its entirety. The contract sets forth the office policies of Westfield Psychiatric Wellness Center and contains many elements important to your care. We take your care very seriously and we want to make sure you agree to all of our policies before you become a client.
Consent for Treatment
I, the undersigned patient or legal guardian, consent to evaluation and follow up treatments by Westfield Psychiatric Wellness Center. I understand I have the the right to be informed of and participate in the selection of treatment modalities. I understand I can terminate consent for treatment at any time and that Westfield Psychiatric Wellness Center may terminate consent for treatment at any time. Potential reasons include but are not limited to misusing psychiatric medications or misusing psychiatric services.
Notice of Privacy
As required by law and professional ethics, we keep all client personal information in strict confidence, except as defined within this contract. I have received the HIPAA Notice of Privacy Practice and I have been provided the opportunity to review it.
There are limits to confidentiality as required by law. Confidentiality cannot be maintained when:
· A patient is in imminent danger of hurting themselves or another party
· There is a suspicion of child or elderly abuse, neglect, or sexual molestation
· The doctor/patient privilege is used to shield the planning of a crime or tort.
If our office is required to release information through subpoena, court order, or other action of law than we will abide by the law and release the required information as directed.
Release of Information
Upon your request and completion of our authorization form, Westfield Psychiatric Wellness Center will release your personal information to third parties as directed by you. This can be helpful to involve other parties in your care, such as family members, schools, and/or professionals.
In the event of an emergency, Westfield Psychiatric Wellness Center may use their professional judgement to release your personal information as they feel appropriate to respond to the emergency. In addition to your emergency contact, the authorities may be notified if Westfield Psychiatric Wellness Center becomes concerned about your personal safety or the safety of someone else.
Our services are provided by appointment only and walk-ins are not accepted; however, there might be instances in which you might call, and an appointment will be available on the same day. You may call our office at 908-233-8065 for any questions or concerns.
Non-urgent and Emergency Contact
I agree to call Westfield Psychiatric Wellness Center for any non-urgent medical or psychiatric issues, including side effects to mediations. Please note your practitioner is not exclusive to this location and not always available when you call, but the office staff will make every effort to return your call within 1 business day. In the event of an urgent situation in which you cannot wait for a return call or in an emergency, I agree to immediately call 911 or go to the nearest emergency room. Please contact Westfield Psychiatric Wellness Center after you received proper emergency assistance so that we can be aware of the situation.
I understand that the initial encounter with Westfield Psychiatric Wellness Center is a consultation. At the end of the evaluation process, I will be provided with a working diagnosis and treatment recommendations which might include services that Westfield Psychiatric Wellness Center is unable to provide. For example, a higher level of care based on current acuity level. Additionally, Westfield Psychiatric Wellness Center might require collateral information from other parties (treatment providers, schools) prior to providing treatment recommendations. I understand that by completing the evaluation process it does not mean that Westfield Psychiatric Wellness Center has assumed responsibility for my care. This will be determined by Westfield Psychiatric Wellness Center based on the treatment recommendations. No prescriptions or refills will be provided until the completion of the consultation and only if Westfield Psychiatric Wellness Center feels it is appropriate.
Phone sessions/Tele-services are done as a courtesy for you and is considered an appointment. Your insurance will be billed, and you are responsible for all co-pays, co-insurance and deductibles.
Medical Records or Requesting a Letter
All medical record request or letter request requires a minimum of two weeks to coordinate with your provider. An appointment must be sheduled with your provider for all paperwork to be filled out. Appointment fees apply. A release of information form must be filled out with the office to begin the process. All paperwork is sent directly to the requesting agent/facility not the patient.
Medical Management and Follow Up Appointments
Appointments can be made by calling the office at 908-233-8065. Patients are always given enough medication until the next office visit. If you have missed or canceled an appointment, you are responsible to reschedule your appointment in a timely fashion to ensure proper treatment and medication management. Consistent follow up appointments are necessary for safe medical care. MEDICATION IS NOT REFILLED ON THE WEEKEND OR AFTER OFFICE HOURS. If the office is not open, please leave a voice mail with your specific request and we will get back to you as soon as possible. Email requests for medication will not be accepted.
Westfield Psychiatric Wellness Center accepts Blue Cross Blue Shield, Cigna and Aetna and to the best of our ability we will check with your insurance carrier to ensure that your insurance will cover the appointment, however you will be responsible for all deductibles, co-insurance and co-pays. We encourage you to contact your insurance company yourself to verify deductibles, co-pays and co-insurance due. Co-pays are due at time of service. All balances must be paid in full before you can be seen by a health professional.
If your check bounces, you will be charged any bank charges incurred by Westfield Psychiatric Wellness Center. In addition, Westfield Psychiatric Wellness Center will only accept cash or credit card from you going forward.
If you are unable to keep your appointment, please call and give the office (or your therapist directly) 24 hours’ notice. Failure to do so would result in a charge of $50.00 for late cancellations and missed appointments.
Credit card Payment Authorization form
I agree to complete the Credit Card Payment Authorization form prior to my initial consultation. I understand my credit card will not be charged until the time of service, unless I cancel my appointment with less than 24 hours of the scheduled appointment time. Failure to pay the agreed amount at the expected time may result in transfer of care. I agree by signing the authorization form I am giving Westfield Psychiatric Wellness Center permission to charge my card for all appointment fees, deductible balances, co-pays and co-insurance balances.
I am responsible for alerting Westfield Psychiatric Wellness Center if my insurance changes and understand that if I switch to an insurance that is not accepted, or I no longer have insurance, I will pay $150 for each medication management appointment and $175 for a therapy appointment.