Office Policies, Consent to Treatment & Financial Responsibility Agreement

Please read the following statements and initial or sign where indicated. We will be glad to discuss any policy with you or answer any question before signing. Upon request, a copy of this agreement will be provided for your records.

I understand that this is a collaborative effort between me and my prescriber, and agree to work with my prescriber and their staff to develop a treatment plan in order to meet mutually agreed upon goals that are designed to address my specific healthcare needs.

I understand that I am entitled to full disclosure of the risks, benefits and alternatives to any proposed or prescribed treatment; that I will take any prescribed or recommended medication only in the manner prescribed; that I will take all appropriate measures to safeguard my prescriptions and medications from loss, theft, and damage; and that if I have questions about my medication or treatment, I will contact my prescriber.

 
I understand that requests for early refills of both controlled and non-controlled substances may not be approved; I affirm that I have read and understand both the CARMAhealth Controlled Substance and Bridge and Early Refill Policies attached to this document.

 
I understand that for serious, life-threatening, and after-hours emergencies, I need to contact 911 or go to the nearest Emergency Room.

Financial Policy/Insurance Submissions

Payment in full is required at the time of service for all non-insured patients and insured patients with past due balances, deductible amounts that have not been met, and any other coverage that could not be verified at the time of service. As the patient, you are required to pay the co-pay/coinsurance at the time of service. Claims are billed to the insurance carrier as a courtesy; however, you are responsible for payment of all charges incurred. Please be advised that there are some medical procedures that your insurance will not cover. Therefore, by signing this document, you agree to be held financially responsible for services rendered on or before the time of medical or behavioral health services. All balances not paid by the insurance carrier within 90 days of the date of service will be your responsibility. We will be happy to refund you for any overpayment after your insurance company has paid in full for covered services.

Insurance Changes

If there are any changes to your insurance information, please notify our office immediately. CARMAhealth will not be responsible for timely filing if we do not receive the correct insurance information prior to or at the time of the visit. You must notify the office of any additional or secondary insurance carrier who is responsible for payment.

Deductibles/Coinsurance/Co-payments

Deductibles, coinsurance and co-payments will be collected at the time services are rendered. These payments are a condition of your insurance policy and are agreed upon by you when you accept their insurance. We also must contract with insurance companies, agreeing to collect co-payments, coinsurance, and deductibles, in order to participate with their plans.

Social Security Number

Our office policy requires your social security number to be provided for billing and insurance purposes. Should you decline to provide your social security number, you must  agree to pay for any services prior to services being rendered.

Returned Checks

All checks returned for insufficient funds, closed accounts or for any other reason will be subject to a $25.00 service charge. In the event of a returned check event, all future payments must be made either by credit card, money order or cash.

I understand that by making this request, I become fully financially responsible for any and all charges incurred in the course of treatment authorized.  I further understand that fees are due and payable on the date services are rendered and agree to pay all such charges incurred in full immediately upon presentation of appropriate statement.  I understand that if I fail to provide all necessary information to file my insurance claim, I will be required to pay all charges in full at the time services are rendered.  A photocopy of this assignment is to be considered as valid as the original.  I hereby assign all medical and behavioral health benefits, to include major medical benefits to which I am entitled.  I hereby authorize and direct my insurance carrier(s), including Medicare, private insurance and any other health/medical/behavioral health plan, to issue payment check(s) to CARMAhealth for medical services rendered to myself and/or my dependents regardless of my insurance benefits, if any.  I understand that I am responsible for any amount not covered by insurance.

Release of Information for Payment Purposes:

I hereby further authorize CARMAhealth to (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for the period of one year.  This order will remain in effect until revoked by me in writing. 

I hereby release CARMAhealth, PLLC and its officers, agents, employees, and any clinician associated with my case from all liability that may arise as a result of the disclosure of information to the above-named Insurance Company(s) or their designated representatives.

By signing this Assignment of Benefits and Release of Information, I acknowledge:

1. I am aware and understand that this authorization will not be used unless the above-named Insurance Company(s) or their designated representatives request records of information for reimbursement purposes, or seek to take action for the referred payment for treatment services.
   
   
2. I agree to participate and assist CARMAhealth, PLLC or its designated representatives with any appeal process necessary to collect payment for the services rendered. 
   
3. I am aware and have been advised of the provisions of Federal and State Statutes, rules and regulations that provide for my right to confidentiality of these records.
   
   
4. CARMAhealth, PLLC is acting in filing for insurance benefits assigned to CARMAhealth, PLLC and it can assume no responsibility for guaranteeing payment of any charges from the Insurance Company(s). 
   
   
5. My medical records are protected under the Federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), 45 C.F.R. Pts. 160 & 164 and cannot be disclosed without written consent unless otherwise provided for in the regulations.

 

 

Financial policies:

I understand that payment is expected at the time of service; that I will be responsible for all of the costs associated with treatment; and that I have the right to ask about fees prior to receiving services.

Payment in full is to be made when services are rendered. Payment may be in the form of cash, money order, VISA, Mastercard, Discover, or American Express.

Checks are payable to “CARMAhealth.” A statement of services and payments will be provided upon request.

I agree to pay the fee that is established by CARMAhealth, PLLC for each service at the time it is rendered according to the fee schedule (available by request).

  

 

Late cancellation, missed appointment and late appointment policies:

All services are provided on an appointment basis. This time will be held for me and is not available for other patients and it is my responsibility to inform CARMAhealth, PLLC by phone at least 24 hours in advance during CARMAhealth business hours if I will not be keeping an appointment.

To maximize the effectiveness of my treatment, I agree to be on time for scheduled appointments. If I am late for a scheduled appointment, I will be charged the full fee for the appointment, and may only be seen for the remainder of my scheduled session. My health care provider has the right to determine if there is enough time to be seen or if I will have my appointment rescheduled.

I understand that in most cases a $60 deposit will be required to secure an appointment as outlined in the attached Financial Policies.

I understand that late cancellations and missed appointments are subject to a service fee, and I understand that arriving more than halfway through a scheduled appointment time will result in a missed appointment and the associated missed appointment fee as outlined in the attached Financial Policies.

I understand that I am expected to keep my balance current, and that any accrued balance due is subject to the attached Financial Policies.

I understand that from time to time the financial policies may be updated; that I will be given notice of changes via my preferred contact method and via the patient portal; and that I am responsible for reviewing and understanding changes to the Financial Policies.

Telehealth policies:

CARMAhealth is committed to utilizing technology to increase access to care for all clients. I may request a telehealth appointment, though it is up to my prescriber’s discretion as to whether my visit is appropriate for a telehealth encounter.

If I do engage in a telehealth encounter I agree that I will treat the visit as I would an office visit. I will connect to the encounter through the CARMAhealth patient portal and its encrypted telehealth platform or another authorized video platform; I will ensure privacy at my encounter site; and I will ensure an adequate internet connection. My device will be enabled with a video camera, video display, microphone, and speakers or headphones all in good working order.

If my internet connection is insufficient, or if my prescriber deems my client-side location to be unsuitable for an encounter (i.e. while driving or in a public space) the encounter will be terminated and treated as a missed appointment. I understand that not all complaints can be safely and effectively addressed via telehealth, and that I may be asked to present for an in-person encounter. I understand that controlled substances (including benzodiazepines, stimulants, and buprenorphine) may not be initiated in a telehealth encounter.

  

 

Patient rights:

I understand that I have the right to be informed of my progress and to review, add, or correct information in my medical record and to get copies for other professionals to use for purposes of treatment. I have the right to get information about my prescriber’s qualifications, including his/her license, education, training, experience, and special areas of practice. I understand that I can ask CARMAhealth PLLC staff about fees, appointment scheduling, and office policies, and that I can have my questions about medication or other prescribed treatments answered. I understand that I have the right to respectful treatment at all times.
 
I am aware that I have the freedom of choice of providers and I am choosing CARMAhealth, PLLC, to provide primary medical and/or mental healthcare services to me. I understand that I may withdraw this consent at any time by informing my healthcare provider in writing. I further acknowledge that the information I provided is correct and that I understand my rights as a patient. I do hereby consent to treatment by the healthcare providers at CARMAhealth, PLLC.

We realize that temporary financial problems may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. We would be willing to discuss reasonable payment plans. If you have any question about the above information, please do not hesitate to ask us.

 

 

Consent for Communication to Initiate Care

The MAP Program is provided by MAP Care Solutions TM , a division of MAP Health Management, LLC (“MAP”). MAP has been referred to me by CARMAhealth to provide recovery support services, and care coordination. By signing my name below, I consent to the following:

I voluntarily present for Peer Support services and consent to initiate the care that MAP staff designate to provide my services. Such services do not include diagnostic procedures, psychotherapeutic treatment, other treatments and medications, pathologic and radiological evaluations and procedures considered advisable in my diagnosis, treatment, and course of care. I acknowledge that no guarantee can be made or has been made as to the results of services or examinations.

I consent to be contacted by MAP for purposes of initiating my care. My name, contact information and health information may be shared with MAP. I understand that my health information may include information concerning mental illness, substance use disorder, communicable diseases such as Human Immunodeficiency Virus (“HIV”) and Acquired Immune Deficiency Syndrome (“AIDS”), diagnoses, treatment progress or any other related information.

By providing an email address or telephone number (whether wireless or landline) to MAP or another healthcare provider who has referred me to MAP, I give my permission and consent to receive emails, pre-recorded/artificial voice messages, telephone call on a recorded line, voicemail recording, and text messages (including automated texts sent using an automatic telephone dialing system, mobile push notifications, or notices and messages through other services made available by MAP or its partners) at the email and/or telephone number (whether wireless or landline) that I have provided.

I understand that this consent shall be in force and effect for one year from signed or until I revoke it. I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.