Patient Consent/Contract for Treatment:
As a participant in treatment for medications and/or therapy, I freely and voluntarily agree to accept this treatment contract as follows:
1. I agree to keep and be on time to all my scheduled appointments.
2. I agree to adhere to the payment policy outlined by this office. Payments must be made via cash, credit card or certified check or cashier check. Personal checks are NOT acceptable.
3. I agree to conduct myself in a courteous manner in the doctor's office.
4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.
5. I agree not to deal, steal, or conduct any illegal or disruptive activities in the doctor's office.
6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.
7. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.
8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.
9. I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating physician.
10. I will let my physician know of all medications that I am being currently prescribed including those given by other treatment providers.
11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.
12. I understand that medication alone is not sufficient treatment for my condition, and I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.
13. I agree to abstain from alcohol, opioid, marijuana, cocaine, and other addictive substances (except nicotine).
14. I agree to provide random urine samples or testing (if requested) and have my doctor test my blood alcohol level.
15. If there is a problem and the patient cannot make the scheduled appointment please call the office and leave a message. Failure to contact the clinic and not showing up at the scheduled appointment may result in a $50.00 fee that will be assessed at the Following visit.
16. We do not take any responsibility for any failure of Insurance Reimbursements. You will be billed for any balances you are responsible for. *Suboxone treatment is a service that is unable to be reimbursed from insurance and is private pay only.
17. You must let your provider or the staff know of any changes in your insurance policy, otherwise, you will be responsible for the charges incurred.
18. If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification on the 90th day.
19. If you are terminated from the practice you will not be able to reschedule with our practice. You will be referred to other providers whom provide similar services.
20. I understand that violations of the above may be grounds for termination of treatment.
This form is called a Consent for Services (the "Consent"). Your therapist, counselor, psychologist, doctor, or other health professional ("Provider") has asked you to read and sign this Consent before you start therapy. Please review the information. If you have any questions, contact your Provider.
Consent for audio recording of sessions:
We would like to inform you that, as part of your treatment and care, we may use an audio recording device during your sessions. The recording is used solely for transcription purposes and is not saved or used for any other purpose.
By signing this consent policy, you authorize us to use an audio recording device during your sessions, solely for the purpose of transcribing the session notes using Deep Scribe AI. We will ensure that the recording is stored securely and will not be shared with any third party unless required by law.
Please be assured that your privacy and confidentiality are of utmost importance to us, and we take all necessary measures to protect your personal information. If you have any questions or concerns regarding this policy, please feel free to discuss them with us.
You have the right to withdraw your consent to the use of the audio recording device at any time. To do so, please inform us in writing and we will ensure that the recording device is not used during your sessions.
Thank you for your understanding and cooperation.
Review the practice policy and Acknowledge:
Emergencies
Within a reasonable time frame, I will respond to any text, email, or voicemail. I can make time for any patient emergencies and want to be available to help you.
My Hours of Preferred Call time is 9am-7pm Mon-Thursday.
Office Visit Policy
All patients will be required to present a valid insurance card (if applicable) and driver's license or photo ID. Payment will be collected at every office visit prior to being seen by the physician.
Refill Policy
Please understand I will honor all refill requests via email or telephone in 48 hours, so please be aware that you will need to call 7 days prior to your "running out" of your medication to obtain this quick response. Otherwise, the expectation is to see your provider on the next or the same business day in the office by scheduling an appointment to obtain a refill, and this may be by another covering physician.
Payment Policy
Payment will be requested at the time of service for all services that are non-covered or determined to be the patient's responsibility, including co-payments. Payment may be made by cash, money order, MasterCard, Visa or American Express (NO PERSONAL CHECKS). You may also pay your bill by phone. My fees are comparable to the usual and customary fees charged by other Behavioral Health physicians/practices in this area.
Insurance Claims/Billing
Faisal Rafiq MD. PC., participates with most major insurance carriers. As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. Please remember, any amount not covered by insurance is ultimately the patient's responsibility. A list of the major insurance companies we participate with is on this website, but please contact your insurance company to confirm that we are still participating. We require that you bring your insurance card and photo ID to all visits.
Cancellation Policy
Please call at least 24 hours before your office visit to cancel an appointment. If you are rescheduling an appointment, please let me know so that I can cancel it and open the time for another patient. You may be assessed a missed appointment fee of $50.00, if you cancel on the same day as your appointment, or miss an appointment completely. Also please keep in mind that 3 consecutive cancellations will be considered as noncompliance/No show equivalent and 2 or more No shows will be grounds for termination of Treatment. Once discharged or terminated from the practice you will not be accepted back.
Financial Policy Waiver/Policy:
We recommend your call your insurance company prior to rendering services from Faisal Rafiq MD. PC. or Any of its clinicians, to avoid such issues as not being reimbursed for your visits or to all ensure we are a covered and paneled provider under your insurance company.We are committed to providing you the best possible care. If you have medical insurance we are anxious to help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding.We will file your insurance claim with your primary insurance for you, however we ask that you pay any co- payment or deductible at the time services are rendered and the balance in full if your insurance has not paid in 60 days. For Insurance Co-payment we accept Cash, Money Order and all Major Credit Cards. We do not accept personal checks.We will do all we can to expedite insurance reimbursement, but you must realize that:
1. Your insurance is a contract between you, your employer and the insurance company. If we participate with your insurance plan, we are under contract to the only charge what your company allows. Since each carriers "usual and customary" fees differ, we will take the appropriate discount when your insurance company pays our practice.
2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. These non-covered services are your responsibility. We must emphasize that as Medical Care Providers; while the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about any of our financial policies or any uncertainty regarding insurance coverage, please do not hesitate to ask. We are here to help you.
3. You agree to reimburse us the fees of any collection agency, which will be added to the account at the time it is placed with a collection agency and may be based on a percentage at a maximum of (your standard contingency rate 35%) of the debt, and all costs, and expenses, including reasonably attorneys' fees, we incur in such collection efforts.
ASSIGNMENT OF INSURANCE BENEFITS & ACCEPTANCE OF FINANCIAL RESPONSIBILITY
I authorize the direct payment of any medical benefits to Faisal Rafiq MD. PC., for services, rendered. I understand I am responsible for any and all usual and customary charges not paid as a result of this assignment. If the account is turned over to a third party, collection agency, or attorney, I understand a 10% service charge (Minimum of $15) will be added to the balance, and I understand I will be responsible to pay all litigation expenses, court costs, and reasonable attorney's fees.
Telepsychiatry Consent:
You MUST be a NEW YORK STATE RESIDENT to participate in tele-medicine services provided by Faisal Rafiq MD. PC. and Proof of residence must be provided prior of to conducting sessions.
The benefits of having a video consultation can be:
Reducing the waiting time to see a specialist or other distant service Avoiding your need to travel to the specialist or distant service Assisting your local health service to better look after you
I know that I might not get all these benefits.
The risks of having a video consultation can be:
A video consultation will not be exactly the same, and may not be as complete as a face-to- face service. There could be some technical problems that affect the video visit.
This health care service uses systems that meet recommended standards to protect the privacy and security of the video visits. However, the service cannot guarantee total protection against hacking or tapping into the video visit by outsiders. This risk is small, but it does exist.
If the video visit does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to-face visit, or a second video visit.
I can change my mind and stop using video consultations at any time, including in the middle of a video visit. This will not make any difference to my right to ask for and receive health care.
I hereby consent to engaging in telemedicine with FAISAL RAFIQ MD. PC., as part of my Psychiatry evaluations and medication management sessions. I understand that "telemedicine" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/ mental information, both orally and visually, to health care practitioners located in New York or outside of New York.
I understand that I have the following rights with respect to telemedicine:
(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.
(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.
(3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my psychotherapist believes I would be better served by another form of psychiatric services (e.g. face-to-face services) I will be referred to a psychiatrist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry, and that despite my efforts and the efforts of my psychiatrist, my condition may not be improve, and in some cases may even get worse.
(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.
(5) I understand that I have a right to access my medical information and copies of medical records in accordance with New York Law.
I have read and understand the information provided above. I have discussed it with my Psychiatrist and all of my questions have been answered to my satisfaction.
THE THERAPY PROCESS
Therapy is a collaborative process where you and your Provider will work together on equal footing to achieve goals that you define. This means that you will follow a defined process supported by scientific evidence, where you and your Provider have specific rights and responsibilities. Therapy generally shows positive outcomes for individuals who follow the process. Better outcomes are often associated with a good relationship between a client and their Provider. To foster the best possible relationship, it is important you understand as much about the process before deciding to commit.
Therapy begins with the intake process. First, you will review your Provider's policies and procedures, talk about fees, identify emergency contacts, and decide if you want health insurance to pay your fees depending on your plan's benefits. Second, you will discuss what to expect during therapy, including the type of therapy, the length of treatment, and the risks and benefits. If your Provider is practicing under the supervision of another professional, your Provider will tell you about their supervision and the name of the supervising professional. Third, you will form a treatment plan, including the type of therapy, how often you will attend therapy, your short- and long-term goals, and the steps you will take to achieve them. Over time, you and your Provider may edit your treatment plan to be sure it describes your goals and steps you need to take. After intake, you will attend regular therapy sessions at your Provider's office or through video, called telehealth. Participation in therapy is voluntary - you can stop at any time. At some point, you will achieve your goals. At this time, you will review your progress, identify supports that will help you maintain your progress, and discuss how to return to therapy if you need it in the future.
IN-PERSON VISITS & SARS-CoV-2 ("COVID-19")
When guidance from public health authorities allows and your Provider offers, you can meet in-person. If you attend therapy in-person, you understand:
• You can only attend if you are symptom-free (For symptoms, see: https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html);
• If you are experiencing symptoms, you can switch to a telehealth appointment or cancel. If you need to cancel, you will not be charged a late cancellation fee.
• You must follow all safety protocols established by the practice, including:
• Following the check-in procedure;
• Washing or sanitizing your hands upon entering the practice;
• Adhering to appropriate social distancing measures;
• Wearing a mask, if required;
• Telling your Provider if you have a high risk of exposure to COVID-19, such as through school, work, or commuting; and
• Telling your Provider if you or someone in your home tests positive for COVID-19.
• Your Provider may be mandated to report to public health authorities if you have been in the office and have tested positive for infection. If so, your Provider may make the report without your permission, but will only share necessary information. Your Provider will never share details about your visit. Because the COVID-19 pandemic is ongoing, your ability to meet in person could change with minimal or no notice. By signing this Consent, you understand that you could be exposed to COVID-19 if you attend in-person sessions. If a member of the practice tests positive for COVID-19, you will be notified. If you have any questions, or if you want a copy of this policy, please ask.
TELEHEALTH SERVICES
To use telehealth, you need an internet connection and a device with a camera for video. Your Provider can explain how to log in and use any features on the telehealth platform. If telehealth is not a good fit for you, your Provider will recommend a different option. There are some risks and benefits to using telehealth:
• Risks
• Privacy and Confidentiality. You may be asked to share personal information with the telehealth platform to create an account, such as your name, date of birth, location, and contact information. Your Provider carefully vets any telehealth platform to ensure your information is secured to the appropriate standards.
• Technology. At times, you could have problems with your internet, video, or sound. If you have issues during a session, your Provider will follow the backup plan that you agree to prior to sessions.
• Crisis Management. It may be difficult for your Provider to provide immediate support during an emergency or crisis. You and your Provider will develop a plan for emergencies or crises, such as choosing a local emergency contact, creating a communication plan, and making a list of local support, emergency, and crisis services.
• Benefits
• Flexibility. You can attend therapy wherever is convenient for you.
• Ease of Access. You can attend telehealth sessions without worrying about traveling, meaning you can schedule less time per session and can attend therapy during inclement weather or illness.
• Recommendations
• Make sure that other people cannot hear your conversation or see your screen during sessions.
• Do not use video or audio to record your session unless you ask your Provider for their permission in advance.
• Make sure to let your Provider know if you are not in your usual location before starting any telehealth session.
CONFIDENTIALITY
Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
• Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.
RECORD KEEPING
Your Provider is required to keep records about your treatment. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record provided by TherapyNotes. TherapyNotes has several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. TherapyNotes keeps records of all log-ins and actions within the system.
COMMUNICATION
You decide how to communicate with your Provider outside of your sessions. You have several options:
• Texting/Email
• Texting and email are not secure methods of communication and should not be used to communicate personal information. You may choose to receive appointment reminders via text message or email. You should carefully consider who may have access to your text messages or emails before choosing to communicate via either method.
• Secure Communication
• Secure communications are the best way to communicate personal information, though no method is entirely without risk. Your Provider will discuss options available to you. If you decide to be contacted via non-secure methods, your Provider will document this in your record.
• Social Media/Review Websites
• If you try to communicate with your Provider via these methods, they will not respond. This includes any form of friend or contact request, @mention, direct message, wall post, and so on. This is to protect your confidentiality and ensure appropriate boundaries in therapy.
• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, they will not follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they will not respond. While you are always free to express yourself in the manner you choose, please be aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.
FEES AND PAYMENT FOR SERVICES
You may be required to pay for services and other fees. You will be provided with these costs prior to beginning therapy, and should confirm with your insurance if part or all of these fees may be covered. You should also know about the following:
• No-Show and Late Cancellation Fees
• If you are unable to attend therapy, you must contact your Provider before your session. Otherwise, you may subject to fees outlined in your fee agreement. Insurance does not cover these fees.
• Balance Accrual
• Full payment is due at the time of your session. If you are unable to pay, tell your Provider. Your Provider may offer payment plans or a sliding scale. If not, your Provider may refer you to other low- or no-cost services. Any balance due will continue to be due until paid in full. If necessary, your balance may be sent to a collections service.
• Administrative Fees
• Your Provider may charge administrative fees for writing a letter or report at your request; consulting with another healthcare provider or other professional outside of normal case management practices; or for preparation, travel, and attendance at a court appearance. These fees are listed in the fee agreement. Payment is due in advance.
• Insurance Benefits
• Before starting therapy, you should confirm with your insurance company if:
• Your benefits cover the type of therapy you will receive;
• Your benefits cover in-person and telehealth sessions;
• You may be responsible for any portion of the payment; and
• Your Provider is in-network or out-of-network.
• Sharing Information with Insurance Companies
• If you choose to use insurance benefits to pay for services, you will be required to share personal information with your insurance company. Insurance companies keep personal information confidential unless they must share to act on your behalf, comply with federal or state law, or complete administrative work.
• Covered and Non-Covered Services
• When your Provider is in-network, they have a contract with your insurance company. Your insurance plan may cover all or part of the cost of therapy. You are responsible for any part of this cost not covered by insurance, such as deductibles, copays, or coinsurance. You may also be responsible for any services not covered by your insurance.
• When your Provider is out-of-network, they do not have a contract with your insurance company. You can still choose to see your Provider; however, all fees will be due at the time of your session to your Provider. Your Provider will tell you if they can help you file for reimbursement from your insurance company. If your insurance company decides that they will not reimburse you, you are still responsible for the full amount.
• Payment Methods
• The practice requires that you keep a valid credit or debit card on file. This card will be charged for the amount due at the time of service and for any fees you may accrue unless other arrangements have been made with the practice ahead of time. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges.
Balances greater than 30 days may be subject to interest charges of 5%, weekly and balances unpaid past 60 -90 days are sent to collections.
There is a fee for NO-SHOW or Same Day cancellation of an appointment - $50 fee; but some exceptions do apply.
COMPLAINTS
If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.
I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of All Policies by Faisal Rafiq MD. PC.