Financial and Medication Policies

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.

1. Late Cancellation/ Missed Appointment
   
   We understand that there are times when you must miss an appointment due to emergencies or obligations for work or family. However, when you do not call to cancel an appointment, you may be preventing another patient from getting much needed treatment. Conversely, the situation may arise where another patient fails to cancel their appointment and we are unable to schedule you for a visit, due to a seemingly full schedule.
   
   If an appointment is not cancelled at least 24 hours in advance, or if you do not present for your scheduled appointment, you will be charged the missed appointment fee.  Note that this fee will not be covered by your insurance company.
   
   As of November 1, 2020, the missed appointment fee is $25.
   
   
   
   
2. Missed or Late Appointments
   
   We understand that delays can happen, however we must try to keep the other patients and providers on time. If a patient is 15 minutes past their scheduled psychiatry appointment time, or 10 minutes past their scheduled primary care appointment time, we will need to reschedule the appointment and charge the missed appointment fee as noted above.
   
   
   
   
3. Scheduling Appointments
   
   All initial and follow-up appointments must be secured with a $60 deposit. This deposit will be credited to your visit fee or may be held in perpetuity to secure all future visits until such time as you may choose to leave the practice.
   
   
   
   
4. Bridge and Early Refill Policy
   
   In the event of a missed appointment, you may be provided medication refills only at your prescriber’s discretion, and only through your next rescheduled follow up appointment. After a second missed appointment you will not be provided medication refills (or will be provided with a taper if appropriate) until a face-to-face follow up appointment is kept.
   
   As providers of primary care, psychiatry, and addiction medicine, it is our greatest desire to provide high quality care to the greatest number of people.
   
   To that end, we need to reaffirm that treatment is a collaboration between the clinic and the patient. It is our responsibility to provide good care and it is your responsibility to make sure your follow ups are scheduled in advance of your need for new prescriptions or refills.
   
   Effective November 1, 2020, we will no longer be providing partial or bridge prescriptions for controlled substances under any circumstance without a visit with and authorization from your provider. If you for any reason are unable to make your appointment and this results in a lapse in your medication prescription, your medication will not be renewed or refilled without first having a provider visit. Controlled substances include buprenorphine, stimulants, benzodiazepines, and some pain medications.
   
   At each appointment, your doctor, nurse practitioner, or physician assistant advises both you and our staff of the timing of your next follow up appointment. It is your responsibility to ensure that a follow up appointment is made within that time frame. Follow up appointments should be scheduled on the same day that you see your doctor or nurse practitioner.
   
   
   
   
5. Controlled Substance Policy
   
   Controlled substance medications can be clinically useful but also have the potential for misuse. Controlled substances include (this is not a comprehensive list):
   Benzodiazepines: potent anxiety-reducing medications such as Valium (diazepam), Ativan (lorazepam), Xanax (alprazolam), and Klonopin (clonazepam), among others.
   Stimulants: potent medications often used in the treatment of Attention Deficit Hyperactivity Disorder (ADHD), and include Adderall and Dexedrine (amphetamine); Vyvanse (lisdexamfetamine); and Focalin, Concerta, Ritalin, and Metadate (methylphenidate).
   Opioid analgesics such as hydrocodone and oxycodone.
   Buprenorphine: an FDA-approved medication for treatment of opioid use disorder, and which may be used for detoxification or for maintenance therapy.
   
   At CARMAhealth, PLLC our prescribers strive to provide quality, individualized care that best addresses client concerns and offers the highest chance at successful treatment. While we acknowledge the efficacy and appropriateness of long-term use of some controlled substances in some patients, we also take into consideration the risk for misuse, abuse, and diversion of these medications.
   
   In order to best protect your health and safety, by signing below you agree to the following:
   
   If you are transferring into our services and are currently on long-term benzodiazepine therapy, we will carefully review your history and plan of care and propose reasonable and evidence-based alternatives to benzodiazepine therapy when clinically indicated. If you are new to our services, you can expect that all other alternatives will be thoroughly exhausted before benzodiazepine therapy is considered as a plan of care.
   
   If you are transferring into our services and are currently on long-term stimulant therapy, we will continue your therapy once you have provided documentation of the diagnosis and of a stable dosing regimen for at least 12 months. If you are new to our services, you can expect that all other alternatives will be thoroughly exhausted before stimulant therapy is considered as a plan of care or if there is evidence from collateral and neuropsychological testing confirming the diagnosis.
   
   If you are prescribed opioid analgesia, you understand that the lowest dose and shortest course clinically indicated will be prescribed, and any refills will be issued only after a face-to-face follow up with your prescriber.
   
   If you are prescribed buprenorphine, you agree to adhere to the office policies regarding buprenorphine prescribing as outlined in the buprenorphine attestation and consent document.
   
   If, after careful review and exhaustion of reasonable alternatives, our plan of care recommends discontinuation of a controlled substance we will collaborate on a discontinuation plan. If you do not agree with a reasonable discontinuation plan, we will work with you to find another provider.
   
   If you are prescribed any controlled substance, you understand that you are responsible for the controlled substance medications prescribed to you. If your medication is lost, spilled, misplaced, misused, or stolen you understand that you will not receive a refill until the next scheduled refill date or after a face-to-face appointment with my prescriber. You understand that early and bridge refills are not part of our standard practice and will require a provider visit and authorization. You agree to comply with random toxicology screens, and consent to random or scheduled medication counts. If called for a random medication count, you must present to the clinic or your pharmacist within 24- hours. You agree to have all prescriptions for controlled substances filled at the same pharmacy, and should the need arise to change pharmacies, the practice will be notified. You agree to comply with your prescriber’s recommendations for additional counseling or other supportive services.
   
   
   
   
6. CONTROLLED SUBSTANCE EARLY AND BRIDGE REFILLS:
   
   CARMAhealth providers generally will not provide partial or bridge prescriptions for controlled substances without a visit with and authorization from your provider. If a patient is unable to make an appointment and this results in a lapse in your medication prescription, your medication will not be renewed or refilled without first having a provider visit. Controlled substances include buprenorphine, stimulants, benzodiazepines, and some pain medications.
   
   At each appointment, your doctor, nurse practitioner, or physician assistant advises both you and our staff of the timing of your next follow up appointment. It is your responsibility to ensure that a follow up appointment is made within that time frame. Follow up appointments should be scheduled on the same day that you see your doctor or nurse practitioner.
   
   
   
   
7. Past Due Account Balance Policy
   
   We will require that patients with self-pay (cash pay) balances to pay their account balances to zero (0).
   
   If you have a past due balance that exceeds $250 you are required to:
   • Make payment for your next appointment in full, and to pay the balance above $250.
   • Establish a payment plan to pay the remaining balance in monthly installments over 3 months.
   • Place a credit or debit card on file to make installment payments.
   
   If you do not adhere to the payment plan, any visit or refill requests during the payment plan period may be declined.
   
   If you have a past due balance that does not exceed $250 you are required to:
   • Make payment for your next appointment in full.
   • Establish a payment plan to pay the remaining balance in monthly installments over 3 months.
   • Place a credit or debit card on file to make installment payments.
   
   If you do not adhere to the payment plan, any visits and refill requests during the payment plan period may be declined.