Please read carefully, sign, and date on the last page.
MEDICATION
Medications may be indicated when your mental symptoms are not responsive to psychotherapy alone. Medication may offer much-needed relief when a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or adequately care for your basic needs. If it is agreed that medications are indicated, we will discuss all available medication options to treat your current condition with you. We will present information in language that you can understand. You will learn how the medication works, its dosage and frequency, its expected benefits, possible side effects, drug interactions, and any withdrawal effects you may experience if you stop taking the medication abruptly. By the end of the discussion, you will have all the information you need to decide which medication is proper. You may already receive psychotherapy from another therapist and are referred to me for medication management. In this case, we will make a solid effort to coordinate care with your therapist (with your consent). We believe communication between mental health professionals is critical to providing adequate care. Not everyone is a good candidate for medication therapy. Such therapy requires strict dosage and frequency adherence, close follow-up, and sometimes regular urine and blood tests. Your adherence to medication treatment will be considered when starting such therapy. Overall, we are strong proponents of the bio-psycho-social medical treatment model. Treatment that considers your biological status, genetics, your psychological development, and social issues together will yield the best chance for success in achieving your goals.
PSYCHOTHERAPY
We will conduct a thorough review of your current complaints and your background. We will offer my preliminary impressions by the end of the initial visit and discuss your treatment options. Sometimes, psychotherapy alone will suffice. However, a combination of psychotherapy and medication management is often optimal. One of the most essential curative aspects of a therapeutic relationship is the goodness of fit between therapist and client. The initial visit is also your opportunity to determine if we are the right providers for you. If you feel that we are not well matched to your needs, we would be happy to provide you with referrals to other mental health professionals. Psychotherapy, or talk therapy, is a powerful treatment for many mental complaints. It offers the benefits of improved interpersonal relationships, stress reduction, and a deeper insight into one’s life, values, goals, and development. It requires a lot of motivation, discipline, and work from both parties for a therapeutic relationship to be effective. Clients will have varying success depending on their complaints' severity, capacity for introspection, and motivation to apply what is learned outside of sessions. Clients should be aware that the process of psychotherapy may bring about unpleasant memories, feelings, and sensations such as guilt, anxiety, anger, or sadness, especially in its initial phases. It is not uncommon for these feelings to impact your current relationships. If this occurs, addressing these issues in the session is vital. Usually, these unpleasant sensations are short-lived.
FREQUENCY AND DURATION OF VISITS
At your initial visit, we will decide together on the structure of your care. If medications are prescribed or changed, we prefer to conduct a follow-up visit in one to two weeks. This is necessary to ensure proper administration and minimize any side effects you may experience. If your symptoms improve, follow-up visits can be spaced out monthly. For some clients on maintenance therapy, follow-up visits can be held at three-month intervals. If you are to undertake psychotherapy, weekly sessions will provide the best results. We may discuss an alternate treatment structure depending on your circumstances.
FEES
Services may be covered in full or part by your health insurance. Please check your coverage carefully before making your appointment. Out-of-pocket rates are as follows: For an initial evaluation our fees are $255.00 for initial evaluation. The fee for a medication management visit is $150.00 unless psychotherapy or other services are provided, and fees will be determined according to the services rendered. Other miscellaneous services, such as filling forms, telephone correspondence, prior authorizations, and court hearings, will require a fee depending on minutes spent to complete task intervals. Fees may change at the medical director and provider’s discretion. Providers specializing in services may offer different fees and may not accept your insurance. If my fees are to increase, we will provide you a thirty-day notice to alert you to the change.
TERMINATION OF CONTRACT
Innovative Treatment Centers LLC is committed to fostering an inclusive, welcoming, and friendly environment for everyone, regardless of race, gender identity or sexual orientation. If efforts to rehabilitate the relationship are not appropriate or unsuccessful, Innovative Treatment Centers reserves the right to end the client-provider relationship under the following circumstances.
Treatment nonadherence: The client does not follow the treatment plan or the terms of a controlled substance contract or discontinues medication or therapy regimens prior to completion.
Follow-up noncompliance: The client repeatedly cancels follow-up visits or fails to keep scheduled appointments with providers or consultants.
Office policy nonadherence: The client fails to observe office policies, such as those implemented for prescription refills or appointment cancellations or refuses to adhere to mandated infection-control precautions.
Verbal abuse or violence: The client, a family member, or a third-party caregiver is rude, uses disparaging or demeaning language, or sexually harasses office personnel or other patients, visitors, or vendors; exhibits violent or irrational behavior; makes threats of physical harm; or uses anger to jeopardize the safety and well-being of anyone present in the office.
Display of firearms or weapons: The client, a family member, or a third-party caregiver wields a firearm or weapon on the premises.
Inappropriate or criminal conduct: The client exhibits inappropriate sexual behavior toward providers or staff or participates in drug diversion, theft, or other criminal conduct involving the practice.
Nonpayment: The client owes a backlog of bills and has declined to work with the office to establish a payment plan or has discontinued making payments that had been agreed on previously.
If termination of client-provider relationship occurs under these circumstances, Innovative Treatment Centers will be sending a letter via email and to address included on file via certified mail. We will continue to provide immediate care for 30 days or until you have secure transfer of care. At the provider’s discretion we may refill your prescription(s) and encourage you to follow with another provider for treatment.
CANCELATIONS AND NO-SHOWS
For commercial insurance and self-pay patients: If you must cancel or reschedule an appointment, we require at least 24-hour notice (weekends not included). If your appointment is on a Monday, the cancellation must be made by the same hour on the preceding Friday. For our Medicare/Medicaid patients: If you must cancel or reschedule an appointment, we require at least 24-hour notice. Cancellations with less than 24-hour notice or failure to attend an appointment will result in discontinuation of care, and a referral will be provided to continue services. More than three no-shows within a 2-month period will result in discontinuation or termination of care, and we will mail you a discharge letter at your address.
PAYMENTS
Full payments are expected at the beginning of each session unless we have agreed on other arrangements. We accept cash or personal check and major credit cards. Checks should be made payable to “Innovative Treatment Centers, LLC.” If payment is 60 days past due, we reserve the right to utilize legal resources such as collection agencies or small claims courts in order to obtain payment for services.
MEDICAL RECORDS
We are required by law to keep complete medical records. Most medical records will be electronically encrypted. Any written records will be stored in a secure file. You are entitled to review your medical records, which will be provided to you for a fee.
CONFIDENTIALITY
The security of sensitive information is of utmost importance to us, and we are bound by law to protect your confidentiality. Any disclosure of your treatment to others will require your explicit written consent. As described above, basic information about your treatment may be disclosed to your insurance company for prior authorizations. There are exceptions to this confidentiality, where disclosure is mandatory. These include the following: A threat of harm to your safety and /or others which may require immediate hospitalization Legal hearings to determine your emotional or cognitive condition. Situations where a dementing illness, epilepsy, or other cognitive dysfunction prevents you from operating a motor vehicle in a safe manner. We will be required to report to DMV. Situations where there is suspicion or evidence of child or elderly abuse. These situations rarely occur in an outpatient setting. If they arise, we will do our best to discuss the situation with you before taking action. In some circumstances, we may find it helpful to consult with other professionals specialized in such situations(without disclosing your identity to them). Cookies are files with a small amount of data, which may include an anonymous unique identifier. Cookies are sent to your browser from a website and stored on your computer’s hard drive. We use “cookies” to collect information. You can instruct your browser to refuse all cookies or to indicate when a cookie is being sent. However, if you do not accept cookies, you may be unable to use some portions of our Service.
CRISP Notice of Privacy Practices:
We have chosen to participate in the Chesapeake Regional Information System for our Patients (CRISP), a regional health information exchange serving Maryland and D.C. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care, and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax, or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will remain available to providers. CRISP Notice of Privacy Practices Acknowledgement Page: We participate in the CRISP health information exchange (HIE) to share your medical records with other healthcare providers and for other limited reasons. You have the right to limit how your medical information is shared. We encourage you to read our Notice of Privacy Practices and find more information about CRISP medical record-sharing policies at www.crisphealth.org.
CONTACT INFORMATION
Our office number is 443-430-2998. We respond to calls and text messages. For non-urgent matters, please allow 48 business hours for a response. Messages left late in the day, on weekends or holidays, may not be returned until the next 1-2 business day. If you or someone close to you is in immediate danger, please call 9-1-1 or proceed to the nearest emergency room. By signing below, you certify that you have read and understand the terms in the Treatment Consent Form. You indicate that you understand and agree to abide by the terms stated above during our therapeutic relationship.
TELEHEALTH INFORMED CONSENT
Telehealth is healthcare provided by any means other than a face-to-face visit. In telehealth services, medical and mental health information is used for diagnosis, consultation, treatment, therapy, follow-up, and education. Health information is exchanged interactively from one site to another through electronic communications. Telephone consultation, videoconferencing, transmission of still images, e-health technologies, patient portals, and remote patient monitoring are all considered telehealth services. I understand that telehealth involves the communication of my medical/mental health information in an electronic or technology-assisted format. I understand that I may opt out of the telehealth visit at any time. This will not change my ability to receive future care at this office. I understand that telehealth services can only be provided to patients, including myself, who are residing in the state of Maryland at the time of this service. I understand that telehealth billing information is collected in the same manner as a regular office visit. My financial responsibility will be determined individually and governed by my insurance carrier(s), Medicare, or Medicaid, and it is my responsibility to check with my insurance plan to determine coverage. I understand that all electronic medical communications carry some level of risk. While the likelihood of risks associated with the use of telehealth in a secure environment is reduced, the risks are nonetheless real and important to understand. These risks include but are not limited to: It is easier for electronic communication to be forwarded, intercepted, or even changed without my knowledge and despite taking reasonable measures. Electronic systems that are accessed by employers, friends, or others are not secure and should be avoided. It is important for me to use a secure network. Despite reasonable efforts on the part of my healthcare provider, the transmission of medical information could be disrupted or distorted by technical failures. I agree that information exchanged during my telehealth visit will be maintained by the doctors, other healthcare providers, and healthcare facilities involved in my care. I understand that medical information, including medical records, is governed by federal and state laws that apply to telehealth. This includes my right to access my own medical records (and copies of medical records). I understand that Skype, FaceTime, or a similar service may not provide a secure HIPAA-compliant platform, but I willingly and knowingly wish to proceed. I understand that I must take reasonable steps to protect myself from unauthorized use of my electronic communications by others. The healthcare provider is not responsible for breaches of confidentiality caused by an independent third party or by me. I agree that I have verified to my healthcare provider my identity and current location in connection with the telehealth services. I acknowledge that failure to comply with these procedures may terminate the telehealth visit. I understand that I have a responsibility to verify the identity and credentials of the healthcare provider rendering my care via telehealth and to confirm that he or she is my healthcare provider. I understand that electronic communication cannot be used for emergencies or time-sensitive matters. I understand and agree that a medical evaluation via telehealth may limit my healthcare provider’s ability to fully diagnose a condition or disease. As the patient, I agree to accept responsibility for following my healthcare provider’s recommendations—including further diagnostic testing, such as lab testing, a biopsy, or an in-office visit. I understand that electronic communication may be used to communicate highly sensitive medical information, such as treatment for or information related to HIV/AIDS, sexually transmitted diseases, or addiction treatment (alcohol, drug dependence, etc.). I understand that my healthcare provider may choose to forward my information to an authorized third party. Therefore, I have informed the healthcare provider of any information I do not wish to be transmitted through electronic communications. By signing below, I understand the inherent risks of errors or deficiencies in the electronic transmission of health information and images during a telehealth visit. I understand that there is never a warranty or guarantee as to a particular result or outcome related to a condition or diagnosis when medical care is provided. To the extent permitted by law, I agree to waive and release my healthcare provider and his or her institution or practice from any claims I may have about the telehealth visit. I understand that electronic communication should never be used for emergency communications or urgent requests. Emergency communications should be made to the provider’s office or to the existing emergency 911 services in my community. I certify that I have read and understand this agreement and that all blanks were filled in prior to my signature, with the opportunity to have questions answered to my satisfaction.