Please choose the reason for your visit below.

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Delaware Behavioral Health all insurance benefits, if any, otherwise payable to me for services rendered.  I understand that I am financially responsible for all charges whether or not paid by insurances. I understand that the information I have given today is correct to the best of my knowledge.  I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

 I agree that while under the care of my prescribing Nurse Practitioner, I will disclose the medications currently prescribed to me as well as any other information relevant to my mental health treatment. I will be forthcoming regarding my healthcare as a whole and I will not take psychiatric medications from any other prescriber. Using my medication for any reason not in compliance with the treatment plan intended by the Nurse Practitioner will likely result in the termination of my relationship with Delaware Behavioral Health, Inc. I will treat the staff in this office with the dignity and respect that I would expect from others. I know that if my behavior does not meet this standard I will lose my right to continue treatment with Delaware Behavioral Health, Inc.

I consent to have Delaware Behavioral Health provide me psychiatric and mental health care.

1.      Scheduling

 

a.       It is the patient’s responsibility to remember their upcoming appointments. Any additional reminders are a courtesy and are not accountable for attendance.

b.      Cancelations that are not made at least 48 hours before an appointment may be subject to fees ($75-$100) and/or discontinuation of service with this office.

 

2.      Prescriptions

 

a.      All prescription refills require 48 hours notice. Patients are responsible for providing the office with adequate notice so that a lapse in medication may be avoided.

b.      All prescriptions are written with a quantity sufficient to last until the patient’s next appointment. Request for early medication refills are the result of noncompliance with treatment and cannot be filled.

c.       A patient’s healthcare professional and their office are not responsible for replacing lost, stolen, or expired prescriptions. A replacement may be issued at the discretion of your psychiatric prescriber.

 

3.      Additional Policies

 

a.      Prior authorizations for medications may take up to a week to be completed and a response received from your insurance company.

It is your responsibility to contact your pharmacy to have them send a request to our office.

b.      Patients may be responsible for amounts not covered by their insurance provider.

c.       Co-pays and deductibles are due at the time of service.

d.      Patients are expected to update the office of any changes in their contact information or insurance.

e.      The staff regularly checks every voice mail-box during the day for new messages and will get in touch with the patients within 24 hours.

f.       Duplicate messages are disregarded as they interfere with the staff’s ability to return the calls of each client in a timely manner.

g.      Medicaid patients that miss or late cancel more than two appointments will be discharged.

**If you are scheduled for an evaluation with our Nurse Practitioner and fail to show for two appointments with your therapist, your evaluation will be canceled.

 

Patient Notice of Privacy for

Protected Health Information

 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

 

PLEASE REVIEW IT CAREFULLY

 

As of February 15, 2003 Compliance Date Privacy Rule CFR 164-520:

Our office is required by law to maintain the privacy of Protection Health Information (PHI) and to provide individuals with notice of our legal duties and Privacy Practices with respect to PHI.  PHI is information that may identify you and what relates to your past, present and future physical and/or mental health conditions and related healthcare services.  This Notice of Privacy Practices (“Notice”) describes how we may use and disclose PHI to carry out treatment and or payment practices as required by law.

 

Our office is required to follow the terms of this notice.  We will not use or disclose information about you without your written authorization, except as described in this notice.  We reserve the right to change our practices and this notice and to make the new noticed effective for all PHI we maintain.  We will provide any revised notice to you.

 

Examples of how we may use and disclose PHI

The following are descriptions and examples of ways we use and disclose PHI:

·        We will use PHI for treatment

·        We will use PHI for to obtain payment from third party payors (i.e. insurance companies)

·        We will use PHI for health care operations

·        We will use PHI with other healthcare providers or facilities in order to assist with your care

·        We will use PHI for business associates (which are some services provided by us through contracts with business associates).  Business associates include companies that assist us with claim submission, provide liability insurance, provide pharmacy system software and support, and shredding services.  To protect PHI about you, we require the business associate to appropriately safeguard the PHI.

 

You can obtain a copy of the Notice upon request at any time.

 

For more information or to report a problem

If you have any questions or would like additional information about the Privacy Practices, you may contact the office at 302-543-4425.  If you believe your privacy rights have been violated, you may file a complaint with the Privacy Officer or with the Secretary of Health and Human Services.