If the patient is receiving psychotherapy from another therapist, and is referred to Evolve Psychiatry for medication management, the provider will make reasonable efforts to coordinate care with the other therapist (with patient consent, of course Evolve Psychiatry believes communication between mental health professionals is key to providing effective care.

PRESCRIPTION MANAGEMENT

• In order to ensure safe and effective medication management, Evolve Psychiatry will assume responsibility for the management of all medications used for patients' mental health, including prescribing, monitoring, and adjusting dosages as needed. This agreement applies to all patients receiving psychiatric care and treatment from Evolve Psychiatry including, but not limited to, medication management services.
• Evolve Psychiatry will only provide prescription refills and/or changes in relation to an office visit with a provider. Medication change requests in between appointments are not allowed.
• Patients prescribed controlled substances cannot concurrently fill prescriptions for any other controlled substances for psychiatric reasons. This includes, but is not limited to, sedatives, opioids, stimulants, and benzodiazepines.
• Patients prescribed controlled substances must abstain from using recreational drugs, including psychedelics, cannabis, and other illicit substances.
• Patients may be subject to random urine drug screenings to ensure compliance with their treatment plan.
• Controlled substances cannot be prescribed for more than 30 days at a time unless a patient's prescription insurance requires 90-day prescriptions via a mail order pharmacy. In such cases, patients will be prescribed a 90-day supply of controlled substances but must still attend monthly visits (see FREQUENCY OF VISITS above).
• Patients may continue daily benzodiazepines for approximately 2 to 3 months while their medication regimen is being optimized. Patients are expected to gradually reduce benzodiazepine use to fewer than 5 times per month in order to continue treatment at Evolve Psychiatry. Ifa patient is unable or unwilling to taper below that threshold, they will be referred to in-person services, subject to provider availability, or to an outside practice.
• There is a fee for re-prescribing any controlled substances related to lost medications without a police report. See the Evolve Psychiatry Financial Policy for more details.
• Repeated misplacement of controlled substances may lead to notification of the state board to ensure compliance with regulatory guidelines and to address potential issues of misuse or abuse.

PATIENT RESPONSIBILITIES

Individuals agree to abide by the following responsibilities:

• Patients will make their best effort to provide medical records that show documentation of their diagnoses, treatment history, and past providers to ensure a smooth transition to Evolve Psychiatry. 
• Inform Evolve Psychiatry of all medications currently being taken, including any over-the-counter medications, supplements, or herbal remedies.
• Patients should bring all prescription bottles or a current detailed medication list to the appointments.
• Patients will attend all scheduled appointments and comply with all treatment plans, medication regimens and follow-up appointments.
• Patients will inform Evolve Psychiatry of any changes in health status, any adverse side effects experienced, and any additional concerns while taking medications for mental health so that Evolve Psychiatry may advise on adjustments in treatment plan in a timely manner.
• Patients will not seek prescriptions for mental health medications from any other healthcare provider without first consulting with Evolve Psychiatry.
• Patients will be required to obtain all medications from Evolve Psychiatry or a designated pharmacy mutually agreed upon by patients and Evolve Psychiatry.
• Patients will comply with random drug testing to ensure compliance with medication regimens and detect any abuse or diversion of mental health medications.
• If patients wish to obtain all mental health medications from another healthcare provider, they may terminate this agreement by providing written notice to Evolve Psychiatry. Patients may continue treatment with Evolve Psychiatry excluding medication management.
• Patients acknowledge that they will not hold Evolve Psychiatry liable for any medical complications such as exacerbation of symptoms, adverse side effects, or medication withdrawal that are a result of a patient's failure to abide by the responsibilities listed above.

PRIOR AUTHORIZATIONS FOR MEDICATIONS AND TREATMENTS

If a prior authorization is required for prescriptions or treatments, Evolve Psychiatry will make every reasonable attempt to get the medication or treatment authorized by the insurance company, however, cannot guarantee approval. If authorization is denied, the patient will be responsible for the cash price of treatment or choosing a different medication/treatment option. An appointment will be necessary to discuss any medication adjustments.

COMMUNICATION WITH STAFF

Notifications are essential for communicating updates to your account, scheduling confirmations, and reminders. For communication between sessions, Evolve Psychiatry staff uses HIPAA-compliant direct messaging through the OnPatient portal as well as e-mail communication and text messaging for reminders,witl permission from the patient. It is strongly encouraged that patients utilize the online patient portal for all correspondence regarding clinical matters. In case of medical or psychiatric emergencies, patients must call the office or visit the closest emergency room. Email, texting, or patient portal messaging are not acceptable forms of communication in a medical or psychiatric emergency.

Automatic appointment reminders via email and text messaging are provided as a courtesy to patients. If a patient chooses to disable email or text reminders, they remain responsible for attending their scheduled appointments and fees associated with missed appointments.

DISMISSAL

Evolve Psychiatry reserves the right to terminate this agreement if a patient fails to comply with any policies or procedures related to treatment or violates any controlled substance laws or regulations. After dismissal, patients will no longer be able to schedule appointments, refill prescriptions, access the portal or contact Evolve Psychiatry for medical care; they must find another provider or facility to transfer care. Evolve Psychiatry will send a discharge letter to the patient's last known address, via certified mail, notifying them of the dismissal. Evolve Psychiatry can forward a copy of medical records to the new provider after a signed consent form has been submitted. Dismissal reasons are, but not limited to, the following:

• Failure to reliably commit to scheduled appointments at least once every 90 days
• Having greater than 2 late cancellations or no-shows in a 12 month period
• Deviating from provider instructions or agreed upon treatment plan
• Repeat requests of medication adjustments in between visits
• Using more controlled substances than prescribed or agreed upon
• Filling psychiatric medications prescribed by an outside provider
• Diverting or sharing medications with another individual
• Missing ordered labs on two or more occasions
• Abusive behaviors towards staff; this includes verbal or written hostility, physical aggression ("You can't do this to me. I almost died because of you. I'm going to report you to the authorities.")
• Manipulative conditional statements (i.e. "I will harm myself if you deny me XYZ medications or don't do what I ask. I will report you to the Medical Board for abandoning me and not giving my medications I cannot live without.")
• Attempting to tarnish the clinic's reputation online (i.e. leaving a bad review because of disagreement with professional team)
• Failure to pay an outstanding balance within 30 days

MEDICAL RECORDS

Evolve Psychiatry is required, by law, to keep complete medical records. Most medical records will be electronic, encrypted and under security. All records, including the initial consent forms, letters, internal and external medical records are maintained in an electronic health record. The patient may access the appropriate parts of the medical record on the patient portal at www.Evolve-Psychiatry.com. The patient is entitled to view the medical record at any time, unless viewing the records jeopardizes his or her emotional or physical well-being. If this is the case, the provider will recommend review of the record with the patient to minimize any confusion or misinterpretation of medical terms. Time spent collecting, printing, copying, and summarizing the medical record will be charged the appropriate fees according to the financial policy.

If a patient requests a copy of medical records to be sent to another physician or to his or her self, a written authorization will be required. The medical records department will notify patients with the processing fees and any additional costs that may incur. Only the records originated by Evolve Psychiatry will be forwarded. All other outside medical records sent to Evolve Psychiatry will need to be independently requested again by their respective originators.

CONFIDENTIALITY

The security of sensitive information is of the utmost importance and Evolve Psychiatry is bound by law to protect patient confidentiality. Any disclosure of treatment to others will require explicit written consent on a Release of Information (ROI) form. As described above, required information about treatment may be disclosed for insurance purposes. If the patient sees another behavioral health provider could collaborate and coordinate care. with written consent from the patient.

There are exceptions to this confidentiality, where disclosure is mandatory. Please note, these situations rarely occur in an outpatient setting. If they do arise, Evolve Psychiatry discusses the situation with the patient before taking action. In rare circumstances it is helpful to consult with other professionals specialized in such situations (without disclosing the client identity These include the following:

• If there is any concern for a threat to the safety of others, the provider is required by law to take protective measures including reporting the threat to the potential victim, notifying police, and escalating the patient to a higher level of care, such as inpatient treatment programs.
• When there is a threat of self-harm, the provider is required to seek immediate hospitalization for the patient and will likely seek the aidof family members or friends to ensure safety.
• In legal hearings, the patient has the right to refuse provider involvement. There are rare circumstances, however, in which the provider may be required by a judge to testify on their opinion of the patient's emotional, or cognitive condition.
• In situations where a dementing illness, epilepsy, or other cognitive dysfunction, prevents the patient from operating a motor vehicle in a safe manner, the provider is required to report this to the DMV.

If a mental illness prevents the patient from providing for his or her own basic needs, such as food, water, shelter, the provider is required to disclose such information to seek hospitalization.

PRACTICE SPACE

Most of the patient/provider visits will be conducted face-to-face via telemedicine or in-person in our clinics. While our offices may be part of a shared office with other mental health professionals, Evolve Psychiatry is in no way a part of any other group practice.

ACKNOWLEDGEMENT

By signing this notice, I acknowledge that I understand and agree to the terms of this agreement.

TELEMEDICINE CONSENT

To better serve the needs of the community, especially in light of the Coronavirus pandemic, health care services are now available using telemedicine. Telemedicine allows the health care provider to see and communicate with the patient in real-time using interactive telecommunications technology. The interaction can involve real-time evaluation, diagnosis, consultation, and treatment of health conditions. Although there are many benefits to telehealth such as increased access to care, there are also some differences between in-person treatment and telehealth. Telehealth requires technical competence on both the part of the patient and the provider in order to be successful. Furthermore, an unauthorized person or persons may access a private patient/provider conversation or access confidential data. There is no guarantee that all treatment of all patients will be effective.

Evolve Psychiatry utilizes telecommunication softwares developed by Dr. Chrono, Google, Doxy, and RingCentral. Evolve Psychiatry uses updated encryption methods, firewalls, and back-up systems to help keep patient information private, but there is always a risk that electronic communications may be compromised, unsecured, or accessed by others.

TELEHEALTH BEST PRACTICES

Because telehealth communications take place outside of our private office there is a potential for other people to overhear sessions. It is important for the patient to make sure that they participate in treatment in a private setting to avoid being disturbed or overheard and where other people are not able to view the electronic device being used for therapy. The telehealth sessions shall not be recorded in any way unless agreed to in writing by mutual consent. Evolve Psychiatry will maintain a record of the session in the same way the provider would maintain records of in-person sessions in accordance with clinic policies.

The nature of electronic communications technologies is such that the provider cannot guarantee that communications will be kept confidential or that other people may not gain access to the communications. The patient should act responsibly for information security on their devices including but not limited to, computer, tablet, or phone) and in their own location. Additionally patients should use secure networks for telehealth sessions, use passwords to protect the device used for telehealth, and avoid sharing telehealth appointment links or information with anyone not authorized to attend the session.

APPROPRIATENESS OF TELEHEALTH

It may not always be appropriate to conduct telemedicine sessions. Evolve Psychiatry will generally not engage in telehealth with patients who are experiencing a crisis situation and/or are deemed to require higher levels of support and intervention. Before engaging in telehealth, the patient and provider will develop an emergency response plan to address any potential crisis situations that may arise during telehealth sessions. A patient's provider can discontinue telehealth services if those services do not appear to have any therapeutic benefit or for other reasons that will be explained to the patient. Evolve Psychiatry will communicate if it is decided that telehealth is no longer the most appropriate form of treatment for the patient. If the patient decides telehealth is not optimal, it is important that the patient communicate their reservation to the provider. The provider and patient, if either or both decide telemedicine isn't sufficient for patient's care, will then discuss options of engaging in referrals to another professional who can provide a more appropriate level of care.

ACKNOWLEDGEMENT

By signing this notice, I acknowledge that I understand and agree to the terms of this agreement.

PRESCRIPTION HISTORY CONSENT

Evolve Psychiatry utilizes an integrated electronic medical record system for tracking prescription information and other related information. Evolve Psychiatry may request, access, and receive patient data from Surescripts. To provide this service, Surescripts connects to a patient's medication history data stored in the databases of community pharmacies and pharmacy benefit managers. Surescripts then presents that data to prescribers through software from a certified vendor.

By signing this agreement, the patient understands that Evolve Psychiatry MD, Inc. ("Evolve Psychiatry") and/or its affiliated entities has deployed an integrated electronic medical record that is used by Evolve Psychiatry, its affiliated entities and healthcare providers and other non-partners healthcare providers such as certain community physicians and physician groups. The patient acknowledges that by signing this form below patient consents to and agrees that Evolve Psychiatry and its affiliated entities and healthcare providers and all other users of the Evolve Psychiatry integrated electronic medical record may request, access, and receive patient's medication history data from Surescripts.

ACKNOWLEDGEMENT

By signing this notice, I acknowledge that I understand and agree to the terms of this agreement.

FINANCIAL POLICY

INSURANCE CLAIMS

Claims will be filed with your insurance company. You will be responsible at the time of service for all co-pays, co-insurance, deductibles and services not covered by your plan. Financial responsibility for services rendered rest with the patient regardless of any insurance coverage. Although we will do everything possible to facilitate reimbursement from your insurance company, we cannot guarantee payment of your claim. We file insurance as a courtesy. Insurance follow-up is the responsibility of the patient. If the claim becomes the patient's responsibility, the claim must be paid within 30 days. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the latest correct insurance information in a timely manner, you may be responsible for the balance of the claim. Claims denied due to "untimely billing," where incorrect insurance information resulted in a late or denied claim submission will ultimately be the patient's responsibility.

REFERRALS

The patient is responsible for obtaining and maintaining valid referrals required by their insurance company for any and all covered services. The Patient Success Team, Evolve Psychiatry's patient services department, will assist in obtaining referrals for treatments as a courtesy. If the patient chooses to undergo any service without a valid referral, the patient is financially responsible for the full charges.

MEDICARE

Evolve Psychiatry accepts Medicare PART B. If Medicare is the patient's primary insurance or only insurance, the patient is responsible for the Medicare deductible and 20% of the charges at the time of service. We will file any secondary insurance claims if a secondary payor is provided. Patients may be asked to sign a waiver for tests/procedures that Medicare does not cover. Patients have the right to refuse these tests/procedures and will be asked to sign awaiver stating that they refused these tests/procedures upon each appointment.

SELF-PAY

Self-pay accounts are patients without insurance coverage, patients covered by insurance plans in which the office does not participate, or patients without an insurance card on file with us. We do not accept attorney letters or contingency payments. It is always the patient's responsibility to know if our office is participating with their plan. If there is a discrepancy with our information, the patient will be considered self-pay unless otherwise proven. Evolve Psychiatry charges for time spent with the provider on records review, direct interview, medication or lab orders, documentation, case discussion with third parties, and billing.

NON-COVERED SERVICES

Please be aware that services received may be non-covered or not considered reasonable or necessary by Medicare or other insurers. Patients must pay for these services in full at the time of visit. Services that are not covered by insurance can be found on the Evolve Psychiatry website.

CREDIT CARD INFORMATION

Evolve Psychiatry accepts all major credit cards, bank cards, and flex pay cards for your convenience. Evolve Psychiatry does not accept cash or checks.

Evolve Psychiatry is committed to prioritizing your healthcare needs and keeping financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for everyone, we require that every patient provide our practice and/or our designated payment agent with their updated debit/credit card information. The applicable payment card information will be truncated and "tokenized" by the payment agent in order to help maintain the security of your payment information.

PAYMENT

Full payment for services are due at time of services rendered unless your health insurance carrier has made prior arrangements. All copayments and deductibles must be paid at the time of service. This arrangement is part of your contract with your insurance company. If the patient is not able to pay the balance before their next scheduled appointment, the patient may be asked to reschedule the appointment or be referred to another provider.

The patient agrees to be fully responsible for any and all charges for services rendered and not covered by his or her insurance plan. In addition, the patient authorizes Evolve Psychiatry MD, Inc. ("Evolve Psychiatry") and/or its affiliated entities or designated payment agent to store patient payment information in the secured manner described above and to apply charges to patient's payment card for all amounts owed to the practice for medical visits, procedures or supplies, including (i) amounts agreed as part of a payment plan, (ii) copayments, (iii) coinsurance (after application of insurance proceeds), (iv) amounts not covered by insurance and/or (v) fees (if applicable) charged by the practice for failure to keep a scheduled appointment or provide timely notice of appointment cancellation. Patient acknowledges that it is the patient's responsibility to maintain up-to-date payment information to avoid disruption in

 

OUTSTANDING BALANCES/COLLECTIONS

Prior to providing additional services to the patient, payment in full of total outstanding balances is required. Patient understands that payment for any outstanding balance will be either discussed with the patient at the beginning of the patient's following scheduled appointment, or automatically applied 30 days after the balance is due on the patient's account, whichever is sooner. In the case of a patient balance that is not satisfied by a charge to the patient's payment method on file, the patient may receive a monthly statement for the outstanding balance. Patient is responsible for paying this balance by its due date in order to avoid paying possible interest and late fees on the balance. Patient understands that transaction receipts will be maintained in the patient chart and are always accessible via the online patient portal. If payment is more than 30 days past due, the patient may be dismissed from Evolve Psychiatry as per the Dismissal Policy in the Treatment Consent. After the balance is 60 days past due, Evolve Psychiatry reserves the right to utilize legal resources such as collection agencies or small claims courts in order to obtain payment for services.

ACKNOWLEDGEMENT

By signing this notice, I acknowledge that I understand and agree to the terms of this agreement.

PRIVACY PRACTICES NOTICE

PROTECTED HEALTH INFORMATION (PHI)

PHI refers to any information in the medical record that could potentially identify you. It includes information about your past, present, and expected future health or condition. Some examples of PHI include but are not limited to name, address, date of birth, phone number, medical record, genetic information, and billing records.

MEDICAL RECORDS

Your medical records are used to provide treatment, conduct healthcare operations, bill, and receive payments. Examples of these activities include 1) Review of treatment to ensure appropriate care, 2) Electronic or mail delivery of billing for treatment to you or other authorized payers, 3) Appointment reminder telephone calls, e-mails and/or text messages, 4) Review of records to ensure completeness and quality of care.

FEDERAL AND STATE REQUIREMENTS

Evolve Psychiatry is required by law to maintain your privacy and protected health information. Evolve Psychiatry is required to abide by the terms of this Notice for as long as it remains in effect. Evolve Psychiatry reserves the right to change the terms of this Notice as necessary and to make a new notice of privacy practices effective for all protected health information. Evolve Psychiatry is required to notify you in the event of a breach of your unsecured protected health information. Evolve Psychiatry is also required to inform you that there may be a provision of state law that relates to the privacy of your health information that may be more stringent than a standard or requirement under the Federal Health Insurance Portability and Accountability Act ("HIPAA")

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Authorization and Consent: Except as outlined below, Evolve Psychiatry will not use or disclose your protected health information for any purpose other than treatment, payment or health care operations unless you have signed a form authorizing such use or disclosure. You have the right to revoke such authorization in writing, with such revocation being effective once Evolve Psychiatry receives the information; however, such revocation shall not be effective to the extent that Evolve Psychiatry takes any action in reliance on the authorization, or if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.

Uses and Disclosures for Treatment: Evolve Psychiatry will make uses and disclosures of your protected health information as necessary for your treatment. Doctors and nurses and other professionals involved in your care will use information in your medical record and information that you provide about your symptoms and reactions to your course of treatment that may include procedures, medications, tests, etc.

Uses and Disclosures for Payment: Evolve Psychiatry will make uses and disclosures of your protected health information as necessary for payment purposes. During the normal course of business operations, Evolve Psychiatry may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. Evolve Psychiatry may also use your information to prepare a bill to send to you or to the person responsible for your payment.

Uses and Disclosures for Health Care Operations: Evolve Psychiatry will make uses and disclosures of your protected health information as necessary, and as permitted by law, for our health care operations, which may include clinical improvement, professional peer review, business management, accreditation and licensing, etc. For instance, Evolve Psychiatry may use and disclose your protected health information for purposes of improving clinical treatment and care.

Individuals Involved In Your Care: If you are unavailable, incapacitated, or facing an emergency medical situation and Evolve Psychiatry determines that a limited disclosure may be in your best interest, Evolve Psychiatry may disclose your protected health information to designated family, friends and others who are involved in your care or in payment of your care in order to facilitate that person's involvement in caring for you or paying for your care. Evolve Psychiatry may also disclose limited protected health information to a public or private entity that is authorized to assist in disaster relief efforts for that entity to locate a family member or other persons that may be involved in some aspect of caring for you.

Business Associates: Certain aspects and components of care at Evolve Psychiatry are performed through contracts with outside persons or organizations, such as auditing, accreditation, strategy and systems consultants, data collection, billing, administrative and legal services, etc. At times it may be necessary for Evolve Psychiatry to provide your protected health information to one or more of these outside persons or organizations who assist us with our health care operations. In all cases, Evolve Psychiatry requires these associates to appropriately safeguard the privacy of your information.

Appointments and Services: Evolve Psychiatry may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request, and Evolve Psychiatry will accommodate reasonable requests by you to receive communications regarding your protected health information from Evolve Psychiatry by alternative means or at alternative locations. For instance, if you wish appointment reminders to not be left on voicemail or sent to a particular address, Evolve Psychiatry will accommodate reasonable requests. With such a request, you must provide an appropriate alternative address or method of contact.

Other Uses and Disclosures: Evolve Psychiatry is permitted and/or required by law to make certain other uses and disclosures of your protected health information without your consent or authorization for the following:

• Any purpose required by law;
• Public health activities such as required reporting of immunizations, disease, injury, birth and death, or in connection with public health investigations;
• If Evolve Psychiatry suspects child abuse or neglect; if Evolve Psychiatry believes you to be a victim of abuse, neglect or domestic violence;
• To the Food and Drug Administration to report adverse events, product defects, or to participate in product recalls;
• To your employer when Evolve Psychiatry has provided health care to you at the request of your employer;
• To a government oversight agency conducting audits, investigations, civil or criminal proceedings; Court or administrative ordered subpoena or discovery requests
• To law enforcement officials, as required by law, if Evolve Psychiatry believes you have been the victim of abuse, neglect or domestic violence. Evolve Psychiatry will only make this disclosure if you agree or when required or authorized by law;
• To coroners and/or funeral directors consistent with law;
• If necessary to arrange an organ or tissue donation from you or a transplant for you;
• If you are a member of the military, Evolve Psychiatry may also release your protected health information for national security or intelligence activities; and
• To workers' compensation agencies for workers' compensation benefit determination.

 

DISCLOSURES REQUIRING AUTHORIZATION

Psychotherapy Notes: Evolve Psychiatry must obtain your specific written authorization prior to disclosing any psychotherapy notes unless otherwise permitted by law. However, there are certain purposes for which Evolve Psychiatry may disclose psychotherapy notes, without obtaining your written authorization, including the following: To carry out certain treatment, payment or healthcare operations (e.g., use for the purposes of your treatment, for our own training, and to defend ourselves in a legal action or other proceeding brought by you), To the Secretary of the Department of Health and Human Services to determine our compliance with the law, For health oversight activities authorized by law, To medical examiners or coroners as permitted by state law, or For purposes of preventing or lessening a serious or imminent threat to the health or safety of a person or the public, as required by law

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION

Access to Your Protected Health Information: You have the right to copy and/or inspect much of the protected health information that Evolve Psychiatry retains on your behalf. For protected health information that Evolve Psychiatry must maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. Requests for access must be made on Release of Health Information Form the Evolve Psychiatry patient portal. You will be charged a copying fee and actual postage and supply costs for mail processing of your protected health information. If you request additional copies, you will be charged additional processing fees for copying and postage.

Amendments to Your Protected Health Information: You have the right to request in writing that protected health information that Evolve Psychiatry maintains about you be amended or corrected. Evolve Psychiatry is not obligated to make requested amendments but will give each request careful consideration. All amendment requests, must be in writing, signed by you or legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, Evolve Psychiatry may notify others if it is believed that such notification is necessary. You may obtain an Amendment Request Form from the front office person or individual responsible for medical records.

Accounting for Disclosures of Your Protected Health Information: You have the right to receive an accounting of certain disclosures made by us of your protected health information after April 14, 2003. Requests must be made in writing and signed by you or your legal representative. Accounting Request Forms are available from the front office person or individual responsible for medical records. The first accounting in any 12-month period is free; you will be charged a fee for each subsequent accounting you request within the same 12-month period. You will be notified of the fee at the time of your request.

Restrictions on Use and Disclosure of Your Protected Health Information: You have the right to request restrictions on uses and disclosures of your protected health information for treatment, payment, or health care operations. Evolve Psychiatry is not required to agree to most restriction requests but will attempt to accommodate reasonable requests when appropriate. You do, however, have the right to restrict disclosure of your protected health information to a health plan if the disclosure is for the purpose of carrying out payment or health care operations and is not otherwise required by law, and the protected health information pertains solely to a health care item or service for which you, or someone other than the health plan on your behalf, has paid Evolve Psychiatry in full. If Evolve Psychiatry agrees to any discretionary restrictions, Evolve Psychiatry reserves the right to remove such restrictions as deemed appropriate. Evolve Psychiatry will notify you of a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communicating your desire to do so to the individual responsible for medical records.

Right to Notice of Breach: Evolve Psychiatry is required by law to protect the privacy and security of your protected health information through appropriate safeguards. Evolve Psychiatry will notify you in the event a breach occurs involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself.

The patient hereby gives consent for Evolve Psychiatry to use and disclose protected health information (PHI) about the patient to carry out treatment, payment and healthcare operations.

ACKNOWLEDGEMENT

By signing this notice, I acknowledge that I understand and agree to the terms of this agreement.

CONSENT FOR PSYCHIATRIC SERVICES FOR A MINOR UNDER AGE 18

THE SHORTAGE OF CHILD PSYCHIATRISTS

Psychiatric services play a vital role in addressing mental health issues in children and adolescents. The prevalence of mental health disorders in children and adolescents has been steadily rising. Various factors contribute to this increase, including societal pressures, academic stress, family dynamics, and the impact of digital media. Geographical disparity further limits the availability of child psychiatrists and poses additional challenges for families seeking specialized care for their children.  In situations where a child psychiatrist is unavailable, seeking treatment from a general psychiatrist who has experience in treating children can be a viable alternative.

TREATMENT TEAM EXPERTISE

Evolve Psychiatry aims to bridge the much needed gap in behavior health care needs for children.  Our providers assigned to minor patients diligently assess their psychiatric needs and provide appropriate care, follow evidence-based treatment guidelines, and regularly monitor the patient’s progress.  While not all members of the treatment team have a child and adolescent speciality fellowship, all psychiatric services provided are performed by qualified professionals with comprehensive training that allows them to effectively evaluate, diagnose, and treat most cases within this age group.  

Certain cases may require specialized expertise beyond the scope of general psychiatry. In such instances, the team at Evolve Psychiatry will refer the patient to either a child psychiatrist or other specialist with specific expertise in managing complex or unique presentations. These referrals aim to ensure the highest quality of care and the most appropriate treatment options for the patient.

INFORMATION SHARING

When it comes to sharing a child's mental health history with parents or guardians, mental health professionals strive to create a safe and trusting environment and prioritize the best interests of the child. They follow ethical guidelines, legal requirements specific to their jurisdiction, and their professional judgment to make informed decisions regarding information sharing.

For younger children, providers typically share the child's diagnosis, treatment options, and progress updates with parents as they play a crucial role in their child's care. However, certain sensitive information may be withheld if the provider believes it could harm the child or damage the therapeutic relationship. This can include details about the child's thoughts, feelings, or experiences that the provider determines should remain confidential to protect the child's well-being.

As children enter adolescence, their right to privacy and confidentiality in mental health treatment becomes increasingly important. In many jurisdictions, teenagers have the right to consent to their own mental health treatment and to keep their information private from their parents.  Providers encourage open communication between the child and their parents, but they also respect the adolescent's right to keep certain aspects of their mental health history confidential so that the patient may feel comfortable discussing their concerns openly. 

Upon turning 18, patients gain full confidentiality over their medical records, and parents or guardians lose automatic access. To continue access, an 18-year-old patient must sign a Release of Information (ROI) form.  If not a ROI is not received,  parents or guardians' access to medical information will be restricted immediately, in accordance with legal requirements.

Circumstances where providers are legally obligated to breach confidentiality and share information with parents or other relevant authorities involve situations where the child's safety is at risk, such as if the child expresses an intent to harm themselves or others, or if there is suspected abuse or neglect.

ACKNOWLEDGEMENT

By signing this notice, I acknowledge the following:

• I have had the opportunity to ask questions and seek clarification regarding the treatment team’s expertise in my child's psychiatric care.
• I give my informed consent for my child to receive psychiatric services at Evolve Psychiatry. 
• I understand and agree to the terms of this agreement and received a copy of the same.