Clearwave Psychiatry New Patient Registration Forms

Riverview Psychiatric Medicine, P.C. d/b/a Clearwave Psychiatry (“Clearwave”) is committed toproviding equal access to care and does not discriminate on the basis of race, color, national origin,age, sex (including gender identity or pregnancy), sexual orientation, disability, illness, condition,creed, religion, veteran status, source of payment (including inability to pay or type of coverage),or any other characteristic protected by law. Accordingly, the following questions are meant to streamline our intake process, consistent with our mission to provide compassionate, personalized,and innovative mental health treatment.

Independent Contractor Physicians

Riverview Psychiatric Medicine, P.C. d/b/a Clearwave Psychiatry ("Clearwave") contracts with independent contractors to provide care to patients. These independent contractors are not employees of Clearwave and Clearwave in no way directs, controls, or influences the care these independent contractors deliver to their patients. Specifically, as of the date of this acknowledgement, Clearwave contracts with the following independent contractors:

• Inner Healing Integrative Psychiatry, PLLC, which is owned and operated by Kimberly Robinson, MD.
• Wilson Psychiatry P.C., which is owned and operated by Kenneth Wilson, MD
• Ellyn Enisman LCSW, LLC, which is owned and operated by Ellyn Enisman, LCSW.

 

By signing below, you acknowledge that you understand that the above independent contractor who may provide you care is not an employee of Clearwave and that Clearwave does not direct, control, or influence the care that they provide to you.

Timing of Establishment of Doctor-Patient Relationship, Non-Discrimination Notice, and Informed Consent for Treatment

I understand that, prior to my initial treatment session, I may undergo a diagnostic evaluation with a Clearwave clinician, team member or an independent contractor. The purpose of this diagnostic evaluation is to assess my mental health status and determine the appropriateness of my potential treatment options, and whether there is an employed or contracted clinician suitable to meet my mental health needs. This evaluation, which may include one-on-one telehealth sessions, questionnaires, and other assessment tools, is solely for assessment purposes and does not constitute the initiation of treatment. I understand no treatment will be provided during the diagnostic evaluation, and a doctor-patient relationship does not form during the diagnostic evaluation and will only form upon the initiation of my first treatment session.

Clearwave, Inner Healing Integrative Psychiatry, PLLC, Wilson Psychiatry, P.C., and Ellyn Enisman LCSW, LLC, are all committed to providing high-quality, compassionate care to all patients. In accordance with New York State guidelines and federal regulations, we do not discriminate against any individual on the basis of race, color, national origin, sex, age, disability, or any other protected characteristic as defined by applicable laws. While we strive to accommodate all patients, there may be instances where we are unable to provide care due to specific medical conditions, treatment requirements, such as where providing care may pose a risk to the patient or others, or where the patient's needs exceed the scope of services we are equipped to provide. Any such decisions are made based on medical necessity and clinical judgment, not on any protected characteristic. Accordingly, I understand that Clearwave, Inner Healing Integrative Psychiatry, PLLC, Wilson Psychiatry, P.C., or Ellyn Enisman LCSW, LLC, have the right to refuse to establish a patient-doctor relationship or continued care and that any such decision is based on non-discriminatory factors in accordance with New York State guidelines and federal regulations.

To the extent an initial treatment session is scheduled, upon commencing my first treatment session, I agree and consent to participation in the health care services offered and provided by Clearwave, Inner Healing Integrative Psychiatry, PLLC, Wilson Psychiatry, P.C., and Ellyn Enisman LCSW, LLC. I understand that I am consenting and agreeing only to those services that the above provider is qualified to provide within the scope of the license, certification, and training of the health care providers directly supervising the services received by the patient.

If the patient is under the age of eighteen (18) or unable to consent to treatment, I attest that I have legal custody of this individual and am legally authorized to initiate and consent to treatment on behalf of this individual.

Notice of Practice Policies:

Please click the following link to view our Notice of Privacy Practices. By signing below, you acknowledge that you have read, understand, and agree to Clearwave's Privacy Practices.

Clearwave Financial Policy

In-Network:

1. To the extent Clearwave has an in-network agreement with your insurance company, you may be responsible for the payment of deductibles, copays, and co-insurances (collectively, "Cost-Sharing Payments"). You are responsible for paying these Cost Sharing Payments at the time of service.

2. In addition, you hereby authorize Clearwave to bill your insurance company for services provided and for your insurance company to pay such sums directly to Clearwave.” If your insurance company remits such payment to you directly, you shall redirect such payment to Clearwave as soon as possible. This authorization shall remain in full force while you remain a patient with Clearwave unless you revoke this authorization by providing written notice to Clearwave revoking same. You also understand that your health information and records will be used, as needed, to obtain payment for your health care services from my insurance company. This may include certain activities Clearwave's staff may need to undertake before your insurance company approves or pays for health care services recommended for you, such as determining eligibility of coverage for benefits, reviewing services provided for you for medical necessity, and undertaking utilization review activities.

3. Payment is subject to the terms of your health plan at the time services are delivered and benefit limitations and/or exclusions. Any estimates provided by Clearwave for your out- of-pocket costs are only provided as a courtesy and Clearwave cannot guarantee that the estimated out-of-pocket cost will be equal to amount you actually owe under your insurance plan. You are responsible for all Clearwave charges for your care.

Out-of-Network:

1. For self-pay and out-of-network care, payment is due in full at the time of service. Please be aware that our charge to insurance may differ from our charge for self-pay patients and the amount your insurance company approves may differ from our actual charge. You are responsible for payment of our actual charge.

2. If coverage for services is denied and you would like to appeal the denial, your insurance carrier may require a letter of medical necessity. We will provide you with a letter upon request.

Cancellation Policy:

1. Any cancellations and/or rescheduling of appointments must be done at least 48 hours in advance of your appointment. Patients who cancel and/or reschedule with less than 48 hours notice or do not show for their appointment will be responsible for the full self-pay rate (not just the co-pay rate). Monday appointments must be canceled by noon of the preceding Friday.

2.Clearwave, in its sole discretion, may choose to waive or reduce certain cancellation fees for extenuating circumstances, however, any waiver or reduction in cancellation fee shall not be deemed a change in the Cancellation Policy and Clearwave reserves the right to enforce its Cancellation Policy on all subsequent missed appointments. Please be advised that most insurance companies do not reimburse for missed appointments and therefore you will likely be personally responsible for any assessed cancellation fee.

3.While Clearwave attempts to always provide appointment reminders, these are done only as a courtesy and failure to receive an appointment reminder does not excuse a late cancellation or a no-show.

Payment Requirements:

1. All patients must have a valid credit card on file. By signing this acknowledgement, you hereby provide Clearwave the authorization to charge your credit card for all sums owed at the time they become due, including applicable deductibles, copays, co-insurances and balance bills.

2. The patient is ultimately responsible for payment. We accept most forms of payment. Payment should be made to Clearwave Mental Health. Returned checks will be charged the entire amount plus a $45 return check fee. Late payments will be charged interest at the rate of 1% per whole or partial month the payment is overdue, or 5% of the total bill, whichever is greater. 

3. If you fail to timely make required payments, Clearwave reserves the right to pursue any and all means to collect outstanding payments. If Clearwave incurs any attorneys' fees and costs in its collections efforts, you shall be responsible for reimbursing Clearwave for all attorneys' fees and costs incurred to the extent permitted by law (If any collections efforts proceed to court, this provision shall be interpreted as a prevailing party fee provision).

 

Authorization to Disclose Medical Records or Health Information:

Charges for Forms:

If you require legal, financial, or insurance forms to be completed by a clinician, you will be charged and billed for the time that clinicians take to fill out the requested documents.

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

I hereby authorize Riverview Psychiatric Medicine PC d/b/a Clearwave Psychiatry (“Clearwave”) to keep my signature on file and charge the provided credit card for services rendered.

Background

A provision in the Social Security Act permits Medicare beneficiaries and physicians to contract privately outside of the Medicare program. Under the law as it existed prior to January 1, 1998, a physician was not permitted to charge a patient more than a certain percentage in excess of the Medicare fee schedule amount. A new provision, which became effective on January 1, 1998, permits physicians and patients to enter into private arrangements through a written contract under which the patient may agree to pay the physician more than that which would be paid under the Medicare program.

A “private contract” is a contract between a Medicare beneficiary and a physician or other practitioner who has opted out of Medicare for two years for all covered items and services he/she furnishes to Medicare beneficiaries. In a private contract, the Medicare beneficiary agrees to give up Medicare payment for services furnished by the physician/practitioner and to pay the physician/practitioner without regard to any limits that would otherwise apply to what the physician/practitioner could charge. 

The purpose of this contract is to permit the patient (who is otherwise a Medicare beneficiary) and the physician to take advantage of this new provision in the Medicare law and sets forth the rights and obligations of each. This agreement is limited to the financial arrangement between Physician and Patient and is not intended to obligate either party to a specific course or duration of treatment.

Patients and physicians who take advantage of this provision are not permitted to submit claims or to expect payment for those services from Medicare. 

Exception:

In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the physician/ practitioner may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary’s behalf. Payment will be made for Medicare covered items or services furnished in emergency or urgent situations when the beneficiary has not signed a private contract with that physician/practitioner. 

A. Obligations of Physician
1.      Physician agrees to provide such treatment as may be mutually agreed upon by the parties and at mutually agreed upon fees.

2.      Physician agrees not to submit any claims under the Medicare program for any items or services even if such items or services are otherwise covered by Medicare.

3.      Physician acknowledges that (s)he will not execute this contract at a time when the patient is facing an emergency or urgent health care situation.

B. Obligations of Patient
1.      Patient or his/her legal authorized representative agrees not to submit a claim (or to request that the physician submit a claim) under the Medicare program for such items or services as physician may provide, even if such items or services are otherwise covered under the Medicare program.

2.      Patient or his/her legal authorized representative agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under the Medicare program for such items or services.

3.      Patient or his/her legal authorized representative acknowledges that that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.

4.      Patient acknowledges that Medigap plans do not, and other supplemental insurance plans may elect not to, make payments for items and services not paid for by Medicare.

5.      Patient acknowledges that (s)he has the right to obtain Medicare‐covered items and services from physicians and practitioners who have not opted out of Medicare, and that the (s)he is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other physicians or practitioners who have not opted out.

6.      Patient acknowledges that (s)he or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.

C. Physician’s Status
Patient further acknowledges his/her understanding that physician (has/ has not) been excluded from participation under the Medicare program under Section 1128.

D. Term and Termination
This agreement shall commence on the above date and shall continue in effect until two [2] years after [s]he signs the affidavit. Despite the term of the agreement, either party may choose to terminate treatment with reasonable notice to the other party. Notwithstanding this right to terminate treatment, both physician and patient agree that the obligation not to pursue Medicare reimbursement, for items and services provided under this contract, shall survive this contract.

I have read and understand the provisions regarding private contracting.

By signing this contract, I accept full responsibility for payment of the physician’s or practitioner’s charges for all services furnished to me from the date written above. 

The Patient and/or the Patient's legal representative:

• Accepts full responsibility for payment of Practitioner's charge(s) for all services furnished by the Practitioner.
• Understands that Medicare/Medicaid limits do not apply to what the Practitioner may charge for items or services furnished by the Practitioner.
  Agrees not to submit a claim to Medicare or Medicaid or to ask the Practitioner to submit a claim.
• Understands that Medicare or Medicaid insurance payment will not be made for any items or services furnished by the Practitioner that would have otherwise been covered by insurance if there was no private contract and a proper claim had been submitted.
• Enters into this contract with the knowledge that he/she has the right to obtain Medicare, Medicaid or other out-of-network insurance covered items and services from Practitioners who do accept Medicare, Medicaid and are in-network providers.
• Is not compelled to enter into this private contract that could be furnished by other Practitioners who accept Medicare, Medicaid and are in-network.
• Understands that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare.
• Has not entered this private contract during a time when the Patient requires emergency care services or urgent care services.
• Acknowledges his/her understanding that the Practitioner has not been excluded from participation under the Medicare program under section 1128, 1156 or 1892 of the Social Security Act.
• Has signed this private contract prior to any services provided under the private contract's terms.
• Understands that either party may choose to terminate treatment with reasonable notice to the other party.
• Understands that the obligation not to pursue Medicare/Medicaid reimbursement for such items or services provided under this private contract shall survive this private contract.
• Agrees that this private contract shall be fully binding on the Parties' heirs and successors.
• Understands that a copy of this private contract will be provided at the request of the Patient and/or to his/her legal representative before items or services are furnished to the Patient under the terms of the private contract.
• Understands that this private contract will be retained (original signatures of both parties required) by the Practitioner for the duration of the private contract.
• Agrees that the Practitioner can supply CMS/Medicare/Medicaid with a copy of this private contract upon request.

I (“Patient”) have elected to receive ‘direct pay’ services provided by (“Practitioner”). I (“Patient”) understand that to receive these ‘direct pay’ services I am required to pay the fees for services at the time services are rendered.

I agree to the following safety measures to ensure my well-being during my mental health treatment with Riverview Psychiatric Medicine PC dba Clearwave Psychiatry and/or TMS Medical of the Hudson Valley PC dba Clearwave TMS Medical (collectively “Clearwave”):

Open Communication: I understand that Clearwave strives to provide a safe and non-judgmental environment for me to express myself. As such, I commit to being open and honest about my thoughts, feelings, and any concerns regarding my safety.

Identifying Triggers and Coping Strategies: I will work with my provider to identify triggers and develop effective coping strategies to manage distressing thoughts or emotions.

Immediate Support and Contact: If I experience thoughts of self-harm or harming others, I agree to contact my mental health provider and/or call emergency services (911) immediately. I have identified a personal emergency contact who I also agree to contact if I need immediate support.

Telehealth Session Requirements: I will ensure I am in a private, distraction-free environment during my telehealth sessions and will not be driving or engaged in other activities.

Confidentiality and Limits: I understand that my mental health provider adheres to doctor/patient confidentiality, but there are legal and ethical obligations to intervene if I am at risk of harming myself or others. If my mental health provider believes there is an imminent threat, he/she may be legally required to involve appropriate authorities and emergency services to ensure the safety of myself and others. Furthermore, I agree to allow my emergency contact to be notified if I am at risk of harming myself or others.

Regular Follow-Up and Review: I agree to attend scheduled follow-up appointments and sessions as recommended by my mental health provider.

Responsibility for Well-being: I acknowledge that while my mental health provider is here to support me, the primary responsibility for my well-being lies with me. I agree to actively engage in my treatment plan and take steps to prioritize my safety and health. I agree to abide by the terms of this Safety Pledge and understand the importance of safety and commit to working collaboratively with my mental health provider to ensure a supportive and secure environment.

This document is an informed consent form designed to ensure that you, as a patient, fully understand and consent to the use of AI scribe services during your medical encounter with Riverview Psychiatric Medicine PC d/b/a Clearwave Psychiatry and TMS Medical of the Hudson Valley PC d/b/a Clearwave TMS Medical (collectively, “Clearwave”).  

 

I.               Description of AI Scribe Services: AI scribe (e.g. Freed) services uses the microphone on a secure smartphone to transcribes—but not record—patient encounters and then uses machine learning and natural-language processing to summarize the conversation's clinical content and produce a note documenting the visit. The AI scribe services with which Clearwave contracts uses technology that is HIPAA-compliant and maintains robust systems to protect all PHI.

 

II.             Purpose and Benefits of Remote Scribe Services: The purpose of AI scribing is to improve the efficiency of your medical encounter by allowing your healthcare provider to focus on patient care while ensuring accurate documentation of the encounter for quality assurance and billing purposes. AI scribing will allow your provider to be even more engaged during your session without the need to continuously document the encounter.

 

III.           Confidentiality and Privacy: Your privacy and the confidentiality of your medical information are of the utmost importance. AI scribe services with which Clearwave contracts adheres to strict confidentiality guidelines. All information transmitted during the encounter will be encrypted to protect your privacy. In the unlikely event that the AI scribe service suffers a data breach that impacts you, you agree that you will not hold Clearwave or its respective officers, directors, managers, employees, contractors and agents liable for any such breach.

 

IV.           Voluntary Participation: Participation in AI scribe services is entirely voluntary. You have the right to refuse the use of AI scribe services at any time during your medical encounter.

 

By signing below, you acknowledge that you have read and understood the information provided in this document, and you voluntarily consent to the use of AI scribe services during your medical encounter.

Because of concerns that there may be a conflict of interest when a physician refers a patient to a health care facility in which the physician has a financial interest, New York State passed a law to protect patients. The law prohibits providers, with certain exceptions, from referring you for clinical laboratory services, pharmacy services, radiation therapy services, or x-ray or imaging services to a facility in which that provider or any of their immediate family members have a financial interest. If certain exceptions in the law apply, or if the provider is referring you for treatment other than clinical laboratory, pharmacy, radiation therapy, or x-ray or imaging services, the provider can make the referral under one condition. The condition is that the provider disclose their financial interest and inform you about alternative providers to obtain these services. This disclosure is intended to help you make a fully informed decision about your health care.

 

            Please allow this disclosure to formally advise you that Randy I. Pardell, MD DLFAPA, owns both Riverview Psychiatric Medicine, PC d/b/a Clearwave Psychiatry (“Clearwave Psychiatry”), and TMS Medical of the Hudson Valley, PC d/b/a Clearwave TMS Medical (“Clearwave TMS”), and as such has a financial interest in both entities. Dr. Pardell employs other psychiatrists, psychiatric nurse practitioners, and social workers to provide services at one or both of Clearwave Psychiatry and Clearwave TMS.

 

            If you were referred to Clearwave Psychiatry or Clearwave TMS from a provider who owns, is employed by, or contracts with one of these entities, please be advised that you are under no obligation to treat with the referring provider, or any other provider at Clearwave Psychiatry or Clearwave TMS. To the extent you wish to explore mental health treatment, you are entitled to seek an alternative provider at another facility. For a list of some of the medical providers within 50 miles of any of our office locations, you may click here, or you may ask our staff to provide you with names and addresses of providers best suited to your individual needs that are nearest to your home or place of work.

 

            By signing below, you acknowledge that you understand the nature of the financial relationship between Clearwave Psychiatry and Clearwave TMS, and that you have your choice of mental health treatment providers and, should you choose to treat with Clearwave Psychiatry or Clearwave TMS, you are choosing to do so without influence.

I request that health information regarding my care and treatment be accessed as set forth on this form. I can choose whether or not to allow the Organization named above to obtain access to my medical records through the health information exchange organization called HealthConnections. If I give consent, my medical records e from different places where I get health care can be accessed using a statewide computer network. HealtheConnections is a not-for-profit organization that shares information about people’s health electronically and meets the privacy and security standards of HIPAA and New York State Law. To learn more visit HealtheConnections website at http://healtheconnections.org/.

The choice I make on this form will NOT affect my ability to get medical care. The choice I make on this form does NOT allow health insurers to have access to my information for the purpose of deciding whether to provide me with health insurance coverage or pay my medical bills.

If I want to deny consent for all Provider Organizations and Health Plans participating in HealthConnections to e access my electronic health information through HealthConnections, I may do so by visiting HealthConnections ee website at http://healtheconnections.org/ or calling HealthConnections at 315.671.2241 x5. 

My questions about this form have been answered and I have been provided a copy of this form.