This is a notice of the policies and procedures of this practice. You have the right to obtain this form for your own records at any time. Please read below and sign in agreeance to the policies and procedures of Valeo Behavioral Health.

Keep up to date with your supply of medication: Patients are asked to track their supply and ensure they have an appointment scheduled before they run out of medication or run out of existing refills. Some patients may find that they become aware of running low on medications only at the last minute, and then have difficulty getting onto the doctor's schedule. Please be proactive in your care and track how much medication you have and how many refills remain on the prescription, and ensure you have an appointment to see the doctor before you run out of medication.

Any lost or stolen prescriptions will not be replaced or rewritten. This includes all benzodiazepines and stimulant drugs. NO EXCEPTIONS. If you miss or cancel an appointment, it is at the provider's discretion to write a prescription for enough medication to last only until the next appointment.

Medication changes will only be addressed during scheduled appointment times. If you are having side effects or urgent issues with the medication you are taking, please call our office to schedule the next available appointment or office staff can send the doctor a confidential message.

Prescribers of Valeo Behavioral Health are unable to provide 90-day prescriptions for controlled substances such as stimulants and benzodiazepines.

If it has been 6 months or longer since your last appointment, you WILL need to be seen for a reassessment before medication will be prescribed.

Our office will assist you in obtaining prior authorization for your medication if needed. You will be responsible for any copayments or deductibles per your insurance contract.

PAYMENTS ARE DUE AT THE TIME OF SERVICE UNLESS PAYMENT ARRANGEMENTS HAVE BEEN REQUESTED AND APPROVED IN ADVANCE. YOU ARE EXPECTED TO PAY ACCORDING TO THE ARRANGEMENT.

We participate with most insurance plans. We will bill your insurance company as a courtesy to you. Although we may estimate what your insurance company may pay, the insurance company makes the final determination of your eligibility. If payment is not received from your insurance company in 45 days, you will be expected to assist in the resolution of the open claim. If the claim continues to be unpaid after 45 days, we reserve the right to bill you directly and you have 30 days from the date of the statement. It is in your best interest to ensure that the correct insurance information is provided at the time of service.

We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Filing a secondary claim is a courtesy of the patient. We will only submit to your secondary carrier if they have electronic submission capability. If no response is received, the balance will be your responsibility. If we receive payment from your secondary carrier, a refund of the overpayment will be made to you.

You may need a referral authorization from your primary care physician. Please be aware of your insurance policies relating to referrals and prior authorizations.

All co-payments, deductibles, and coinsurance must be paid at the time of service. This arrangement is part of your contract with your insurance company.

All patients must complete our patient information form before seeing our providers. We must obtain a copy of your driver's license or government administered identification and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

We accept payment by cash, Visa, MasterCard, and Discover. We do not accept checks for payment.

Should we make an exception and accept a check for payment, you will be responsible for the amount of check plus returned check fee of $35.00.

Self-pay rate for the initial assessment is $260.00 and follow-up visits are $145.00. We are committed to providing access to care for everyone. Suboxone self-pay rate for the initial assessment is $300.00 and follow-ups are $160.00 This applies to existing patients as well.

If you fail to meet your financial obligations in a timely manner, we reserve the right to discontinue care and refer your account to a collections agency. You are responsible for any interest, agency, and legal fees associated with collections. If you have an unpaid balance you will receive a statement by mail monthly. If you fail to pay, your balance will be sent to a collections agency with 33.33% of the balance due.

Cancellations for regular office visits: A minimum of 1 business day notice must be given when cancelling your appointment to avoid a charge. This will allow us to reach someone on our waiting list and offer him or her the appointment time. Failure to give notice of at least 1 business day for cancellations will result in a charge of $50.00. This is due ON OR BEFORE your next appointment. We realize that emergencies do happen, but this allows us to meet the needs of all of our patients.

For new patient evaluations, we ask you to give 24-hour notice for cancelling. If you do not provide 24-hour notice, we may choose to not reschedule your appointment.

If you arrive late your appointment may be cancelled and will need to either reschedule or be seen after other patients. Punctual arrivals will have priority.

Multiple late cancellations, no-shows, and other forms of non-compliance with treatment may result in termination of service.

As a courtesy, we offer reminder texts about your upcoming appointment, typically 72 hours and 24 hours in advance. Due to unforeseen circumstances, we are not always able to do so, but please remember that you are ultimately responsible for your scheduled appointments.

Please allow 14 business days for requested form completions (letters, FMLA, Disabilities, etc.). No patient paperwork will be completed on the first patient visit. Please be aware fees may apply.

Please sign if you have read through, understand, and agree with all of our office policies and procedures.

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. We care about our patients and strive to protect the confidentiality of your medical information at this practice. New federal legislation requires that we issue this official notice of our privacy practices. You have the right to the confidentiality of your medical information, and this practice is required by the law to maintain the privacy of that information. This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect and to provide notice of its legal duties and privacy practices with respect to protected health information. If you have any questions about this notice, please contact the manager of this practice.

You have the right to inspect and copy billing records but do not include psychotherapy notes, information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to the Privacy Officer at this practice. If you request a copy of the information, we reserve the right to charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances.

You have the right to a paper copy of our current Notice of Privacy Practices at any time. To obtain a paper copy of the current notice, please request one from the manager at this practice. How We May Use and Disclose Medical Information About You The following categories describe different ways that we may use and disclose medical information without your specific consent or authorization. Examples provided for each category of uses or disclosures. Not all possible uses or disclosures are listed

• For Treatment: We may use medical information about you to provide you with medical treatment or services.

• For Payment: We may use and disclose medical information about you so that the treatment and services you receive from us may be billed and payment may be collected from you, an insurance company or a third party.

• For Health Care Operations: We may use and disclose medical information about you for health care operations to assure that you receive quality care.

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you

Any health care professional authorized to enter information into your medical record, all employees, staff, and other personnel at this practice who may need access to your information must abide by this notice. All subsidiaries, business associates (e.g. a billing service), sites, and locations of this practice may share medical information with each other for treatment, payment purposes, or health care operations described in this notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared. 

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you give us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reason covered by your written authorization. We are unable to take back any disclosures we have already made with your authorization, and we are required to retain our records of the care we have provided you for a period of time.

You have the right to request restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment. To request restrictions, you must submit your request in writing to the Privacy Officer at this practice. In your request, you must tell us what information you want to limit. Right to an Accounting of Non— Standard Disclosures: You have the right to request a list of the disclosures we made of medical information about you. To request this list, you must submit your request to the Privacy Officer at this practice. Your request must state the time-period for which you want to receive a list of disclosures that is no longer than six years from the time of request. The first list you request within a 12-month period will be free. For additional lists, we reserve the right to charge you for the cost of providing the list.

We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice, with the effective date on the posted copy.

The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and authorizes services, Valeo Behavioral Health These services may include medication therapy, laboratory tests, and diagnostic procedures. The undersigned understands that he/she has the right to Be informed of and participate in the selection of treatment modalities, Receive a copy of this consent, Withdraw this consent at any time. I have read, understood and agreed to all the statements in this notice. I understand how my medical information may be used and the purpose of its use.

I authorize Valeo Behavioral Health, associates and employees to share and receive confidential record information with and from the following person, people and/or agencies:

Information shall consist of: Duplicate records and/or verbal consultation concerning treatment and/or education.

The information is needed for the purpose of adopting a more comprehensive and integrated approach to my health care and maintaining a continuity of care for this purpose only unless otherwise permitted or required by law. This authorization may be revoked at any time by the client. Revoking of this authorization shall not cancel any prior action that has already transpired. If not revoked, it shall terminate one year from the last day of the clinical treatment. A photocopy, facsimile or duplicate copy of this authorization shall be as valid as the original. The person signing this consent has a right to receive a copy of it. My initials indicate that I have received a copy of this authorization to release medical records. I have read and understand the nature of this release. I understand that I may revoke it at any time. I release the director, therapists, employees and the above-named organizations from any liability that may arise from this action whether or not foreseen at present. I understand that certain medical records (including any alcohol and drug abuse information...) may be protected by Federal Regulations. ...Drug Abuse Office and Treatment Act of 1972 21 U.S.C. 1175; Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (42 U.S.C. 4582).

Witness Date *PRIVACY ACT STATEMENT: 1. The authority for soliciting the information comes from so USC 3012 2. The purpose for soliciting the information is to provide the therapist/counselor data to assist in counseling you are seeking. 3. The information will be maintained under strict professional guidelines and until, by law, your records are released to be destroyed. 4. Providing the information is voluntary. There will be no adverse effect on you for not furnishing the information other than that certain data might not otherwise be available to the counselor/therapist to enable him/her to provide you the most effective therapy