NASHVILLE NEURO PSYCHIATRIC ASSOCIATES

Craig Clark, MD, Amy Powell, MA, LPE, Justin Malais,PMHNP Tim Caldwell MA,MS, LPC/MHSP(temp), Alyssa Mielock PhD(post-doc)

If Client is Minor or Dependent:

Payment Policy: Payment is expected at the time of service. NNPA requires a credit card be provided to be kept on file. Your card will be charged at the time of your appointment. NNPA providers do not participate in any insurance networks including Medicare and TennCare. We will provide diagnosis and cpt codes for clients to request reimbursement for out of network providers from their commercial insurance.

Credit Card Type (check one): [ Visa MasterCard Discover

I/we authorize Nashville Neuro Psychiatric Associates to charge the above credit card account for professional services provided and receive electronic invoices to the designated email. I will notify Nashville Neuro Psychiatric Associates if I wish to revoke authorization privileges.

Guarantor Information (complete only if the client is not funding services):

Guarantor-Financial Responsibility Agreement: I, undersigned, regardless of any insurance coverage, assume financial responsibility for all charges generated for this client. Office policy requires payment at time of service.

Appointment Changes/ Cancellations: NNPA has a 24hour cancellation policy. Patients WILL BE charged the full session rate when an appointment is missed or if an appointment is cancelled without giving a full business day notice. If you need to change or reschedule, please call our office as soon as possible SO we may accommodate other

Office hours are 8:30 a.m. to 4:30 p.m. If you are experiencing an emergency go to your nearest Emergency Department or call 911.

Prescriptions: Please request prescriptions at least 24 hours in advance. Same day service for prescription refills cannot be guaranteed. Effective January 1, 2021, the state of Tennessee has mandated that all schedule II through V prescriptions be e-prescribed. As a result of this requirement, physician time surrounding the execution of a prescription have increased significantly. There is no charge for e-prescriptions if in conjunction with a face-to-face appointment or telehealth appointment. If prescriptions are required outside of scheduled appointments, charges will be $25 for a month refill and $45 for 90 days.

Email Policy: Charges for clinical communication with Dr. Clark, via email begin at $45 and may increase to $100. depending upon the complexity of the questions and circumstances. By agreeing to communicate via email, you are assuming a certain degree of risk regarding breach of privacy beyond that inherent with traditional communication (i.e. telephone, written, face-to-face NNPA has taken appropriate HIPAA compliant safeguards toward digital security, however we cannot ensure the confidentiality of our electronic communications against purposeful or accidental network interception. Due to this inherent vulnerability, we will save email correspondence with you and these communications should be considered part of the medical record. Therefore, you should consider our electronic communications may not be confidential and will be included in your medical record. Do not send emails of an urgent or emergent nature and please contact our office if you have not received a reply within 24 hours. Emails and text messages are considered confidential information and will be included

Letter Request Letters for accommodations, disability, and other special circumstances may be requested as needed. Charges for letters begin at $100. And upward depending on the time required to construct the

Outpatient treatment is a voluntary service. Clients are not obligated to continue treatment. If you decide to terminate at any time, you are encouraged to discuss your decision with your provider

I have chosen to receive mental health services in the form of individual, group, and/or medication management for myself and/or my child from Nashville Neuro Psychiatric Associates. My decision is voluntary, and I understand that I may terminate these services at any time, unless my participation has been mandated by a court of law.

Nature of Mental Health Services

I understand that during the course of treatment, I may need to discuss material of any upsetting nature in order to resolve my problems. I also understand it cannot be guaranteed that I will feel better after completion of treatment.

Compliance with treatment plan I agree to participate in the development of an individualized treatment plan. I understand that consistent attendance is essential to the success of my treatment. Frequent "no shows" and/or late cancellations may be grounds for termination of services, as well as failure to follow my treatment plan in any form.

Supervision I understand there are certain circumstances which may require NNPA provider(s) to receive supervision. These circumstances include, but are not limited to the following: 1. State licensure regulations may require my therapist or service provider to receive ongoing supervision 2. Accreditation organizations, as well as insurance companies, may require that my treatment plan be reviewed 3. The standards of care which guide most mental health professional recommend that supervision and/or consultation be obtained in high risk situations such as threats and/or acts of harm to self or others 4. Other special circumstances, such as preparation to testify in court

The right to be treated with dignity and respect by all staff The right to be involved in the planning and/or revision of my treatment plan The right to know about my treatment progress or lack thereof The right to reject the use of any therapeutic technique, and to ask questions at any time about the methods used The right to be spoken to in a language that is fully understood The right to a clean and safe environment The right to refuse to be videotaped, audio recorded, or photographed The right to end treatment at any time unless court ordered The right to file a complaint or grievance about the agency or staff The right to confidentiality of clinical records and personal information according to federal and state laws

Emergencies I understand I may reach my NNPA provider at 629-203-6779. If not available, I can leave a message and my call will be returned as soon as possible. If I have a life-threatening emergency situation, I may call 911 or go to the nearest Emergency Department.

I have read, discussed, and understand the above information.

Acknowledgement I have read the policies included in this document and understand and agree to each as outlined. I agree to be treated by the providers at Nashville Neuro Psychiatric Associates, Craig Clark, M.D., Amy Powell, MA; LPE, Alyssa Mielock, PhD, Justin Malais, PHMNP, and Tim Caldwell, LPC/MHSP, and when necessary, any physician covering for Craig Clark M.D., in his absence. I willingly assume responsibility for all charges for services rendered and agree to adhere to payment policies. I hereby authorize my individual provider to release any/all information regarding patient care to my insurance company, should I request. Client signature (Parent / Guardian if minor):

NASHVILLE NEURO PSYCHIATRIC ASSOCIATES

Informed Consent for Telehealth

Please review and sign below regarding information concerning your (or your child's) participation in telehealth (video/telephone Telehealth refers to providing psychotherapy services (individual or group) remotely using telecommunication technologies such as video conferencing or telephone. Telehealth ensures continuity of care when circumstances prevent the client and provider from meeting face to face. Telehealth requires some technical competence from both parties and our providers will instruct you step by step. Our office utilizes Zoom and Teams teleconferencing with HIPAA compliant safeguards. Some differences and risks from in-person psychotherapy and telehealth are listed below: Risks to confidentiality - Please make sure you participate in therapy in a private room or area where others are not present and may not overhear your conversation. Technology issues - Depending on the device and internet connection, a conversation could be interrupted or lost during a session. Although unlikely, it is possible that a third party could gain access to our private conversation. Crisis management and interventions - Telehealth is not appropriate for crisis situations. Should a situation arise that concerns harm to self or others, please go to the nearest emergency department or Vanderbilt Behavioral Health. Efficacy - Research has demonstrated that telehealth is an effective form of service delivery. However, there is debate among therapists as to the significance of reduction in non-verbal information when working remotely. Electronic communications - We will decide together if you prefer telehealth via voice (telephone) or video (Zoom If you plan to submit insurance claims for telehealth services, contact your insurance company in advance to determine if this is a covered benefit. Confidentiality - We have taken appropriate steps to ensure your confidentiality and that HIPAA requirements are in place. However, the nature of electronic communication technology is such that we cannot guarantee that others may not gain access to our communication. You can take steps to ensure the security of our communication by using secure networks and having passwords to protect the device you use for telehealth. Appropriateness of telehealth - Ongoing telehealth will be determined on a case by case basis. You and your provider will determine the most appropriate form of treatment. Emergencies and technology - Assessing and evaluating emergencies and crisis situations can be challenging when relying on telehealth. To address this potential situation, we ask that you provide an emergency contact person (and telephone number) who is near to, or at your location. By signing below, you allow contact with this person in the event of a crisis or emergency.

Interruption - In the event that your session is interrupted for any reason, your provider will reach out to you at the number you designate below (client contact number) or you may contact our office at 629-203-6779.

Please complete the information below:

By signing below, I am indicating that I have read, understand, and agree to the information and limitations as outlined by the NNPA Informed Consent for Telehealth.

NASHVILLE NEURO PSYCHIATRIC ASSOCIATES

Good Faith Estimate for Heath Care Items and Services

Beginning January 1, 2022, mental health providers are required by law to give uninsured and self-pay patients a good faith estimate of costs for services that they offer, when scheduling care or when the patient requests an estimate. These new regulations implement part of the "No Surprises Act," enacted in December 2020 as part of a broad package of COVID- and spending-related legislation. The act aims to reduce the likelihood that patients may receive a "surprise" medical bill by requiring that providers inform patients of an expected charge for a service before the service is provided.

Craig Clark MD Amy Powell-Clark MA, Licensed Psychological Examiner Justin Malais PMHNP, Nurse Practitioner Tim Caldwell MS, MA, LPC/MHSP - temporary licensure Alyssa Mielock PhD (post-doc) - supervisor Patti Van Eys PhD

Primary Service or Item Requested/Scheduled: Psychotherapy

CPT Code: 99214 for medication and therapy and 90837 for therapy only

Diagnosis Codes (ICD-10): Depression F32.0 Anxiety F41.1

Please note: Federal law requires this Good Faith Estimate be provided and include diagnostic information before we will have met for enough time to finalize any diagnosis (in most cases Because of this, the above diagnostic information may be an initial impression that will be finalized over time. Please request an updated Good Faith Estimate at any time.

Charges per session: Craig Clark MD - $395 per hour and $220 per half hour (Initial new client session $795) Amy Powell-Clark MA, LPE - $275 (Initial session $350) Justin Malais PMHNP- $275 per hour and $140 per half hour (Initial new client session $325) Alyssa Mielock PhD (post-doc) - $225 per hour (initial new client session $350) Tim Caldwell LPC/MHSP(temp) - $225 per hour(initial new client session $350)

Based on a projection of an industry standard of a minimum of 10 sessions of treatment, 1x per week or 1x per month, (including the initial new client session cost) the anticipated expense is included in the table below:

Craig Clark MD Amy Powell-Clark MA Alyssa Mielock PhD (post-grad) Tim Caldwell LPC/MHSPC (temp) Justin Malais, PMHNP

Treatment Sessions 1hr 10 sessions 10 sessions 10 Sessions 10 Sessions 10 Sessions

CPT code 99214 90837 90837 90837 99214

$4350 $2825. $2375 $2375 $2800

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created, SO actual services and charges could differ from the estimate. Further, if additional services are recommended for your care and are scheduled separately, their costs may not be reflected above. This Good Faith Estimate is not a contract and does not require you to obtain the services or items identified above. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment or ancillary services such as testing, TMS, or Neurofeedback. You could be charged more if complications or special circumstances occur. For example, as noted in the informed consent information provided to you, services such as report writing, certain types of telephone meetings, requested attendance at some meetings/consultations, preparation of treatment summaries, or other currently unscheduled services are costs that could arise during treatment. Also, for clients in crisis or for some other reason, it may be important to meet more frequently than currently planned. Please contact your provider if there are questions or concerns regarding your bill or for updating this Good Faith Estimate. If you are billed for at least $400 more than this Good Faith Estimate, you have the right to dispute (appeal) the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. It is possible that any issues could be easily addressed with your provider.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises or https://www.hhs.gov/about/contact-us/index.html. The initiation of a patient-provider dispute resolution process will not adversely affect the quality of health care services you receive. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises or https://www.hhs.gov/about/contact-us/index.html.

Complete following pages if scheduled with Alyssa Mielock PhD (post-doc)

NASHVILLE NEURO PSYCHIATRIC ASSOCIATES

Alyssa Mielock, Ph.D. Nashville Neuro Psychiatric Associates 1704 Dorothy Place, Nashville TN 37212 Ph: 629-203-6779

Counseling Policies and Agreement Please read the following counseling policies and agreement carefully and sign where indicated. This agreement will serve as a contract between you and practitioner, Alyssa

Communication is the cornerstone of an effective therapeutic relationship. Please ask any question you may have regarding services. The following information addresses frequently asked questions. Benefits and Risks of Therapy Research has demonstrated that therapy is beneficial for a wide array of issues for children, adolescents, and adults. Most clients receiving counseling services make significant improvements in comparison to those with similar issues who do not receive therapy. It should be understood, some people do not rate problems as significantly improved at the end of treatment and others, a relatively small percentage, rate themselves as worse after receiving treatment. Individuals initiating counseling services often make significant changes in emotions, attitudes, and behaviors. Clients may feel empowered to initiate personal change related to self-care, employment, and relationships. The degree of personal change varies greatly and correlates with the level of client investment (and parent Exploring personal issues may bring about some discomfort and distress before improvement is recognized. If you

have questions not presented in this information, please ask Dr. Mielock for additional

Confidentiality Therapists are bound by legal, ethical, and moral obligations to keep all information shared from a client, confidential. Patient information in all forms, is protected by state and federal laws. HIPAA, the Hospital Insurance Portability and Accountability Act of 1996, is a federal law that mandates standards to protect patient health information from being disclosed without the patient's consent or knowledge. In certain instances, confidentiality may be legally compromised in order to protect the client or others. Situations or threats of harm to self or others are of the highest concern. Tennessee state law requires child abuse to be reported to the Department of Human Services (Tennessee Code Annotated 39-15-401 Communications between the therapist and client, (verbal, written, email, text) become part of the medical record. HIPAA covers information during telehealth

Patients under the age of 18 years require a parent or legal guardian to provide consent in order to receive services. For clients under the age of 18 years, confidentiality will be protected and only general information such as themes, progress, and diagnostic impressions will be discussed with the minor's parents or legal guardian. Please discuss your concerns regarding limitations of confidentiality with Dr. Mielock. HIPAA rights are provided at the end of this information. When a physician or other professional refers a client for services, communication regarding treatment considerations will be maintained with that professional source unless the client specifies to the contrary. Other referral sources will be informed that services are being rendered with no other treatment details.

Dr. Mielock is provisionally licensed by the State of Tennessee as a Psychologist and is designated as a Health Service Provider with Clinical areas of competence. Dr. Mielock is supervised by Dr. Patti Van Eys, PhD who is licensed by the State of Tennessee and is designated as a Health Service Provider with Clinical areas of competence under the regulations of the Tennessee Department of Health. As a provisional licensee, Dr. Mielock is supervised by a fully licensed psychologist, Dr. Patti Van Eys. As a supervisor, Dr. Van Eys will have access to all clinical information

regarding Dr. Mielock's clients, including personally identifying information, progress notes, psychotherapy notes, and testing results. Dr. Mielock completed her M.A. and Ph.D. programs at Northern Illinois University and clinical internship at the Anne Arbor VA Healthcare System. Her clinical practice is grounded in evidence-based treatments of Acceptance and Commitment Therapy, Cognitive Behavioral Therapy (CBT), Exposure and Response Prevention (ERP), and Dialectical Behavioral Therapy (DBT

Fee-for-service Acknowledgement Statement and Agreement

I understand NNPA providers utilize a fee-for-service model and do not participate in any insurance networks. Payments are made by cash, check or credit card for the full amount at time of service. Clients under the age of 18 years who attend sessions without parents will be expected to bring payment at time of service or parents will keep a credit card on file for service charges. For families seeking reimbursement from their private insurance, CPT codes (procedure) and diagnostic codes can be provided. Failed appointments This office, NNPA, does not over-book appointments and considered a reservation of resources specifically for the individual client. Charges are submitted for appointments that are not cancelled 24-hours prior to the scheduled time.

The fee for the initial intake is $350 (60 minutes) and return appointments are $225 (50 minutes Charges associated with psychological testing or psychoeducational evaluations will be considered on a case-by-case basis. Consultations on behalf of the client with other professionals by phone or telehealth will be charged at the hourly rate or the fraction thereof. This agreement supplements previous informed consents at NNPA. Your signature below indicates you have read, understand, and agree to the information in this document and agree to abide by those terms during our professional relationship.

HIPAA / Client Rights (review and sign)

Patient/Client Rights under HIPAA There are six main patient rights under HIPAA, as detailed below.

Notification of Privacy Practices HIPAA-covered entities are required to notify you about how your medical data will be used. This information is provided in a Notice of Privacy Practices or NPP. The NPP should be posted on your provider's website and should be given to you to sign when you first visit a new healthcare provider or sign up with a health plan.

Right to Obtain a Copy of Your Health Data One of the most important patient rights under HIPAA is the right to view or obtain a copy of your health data. By obtaining a copy of your health records you can check the data for errors, keep a copy for your own records, and share your health information with whoever you wish.

You can exercise this right by submitting a request in writing. Most healthcare providers will require you to fill in a form. A copy of your medical records must be provided within 30 days. You can specify how you want to receive the information - electronically or a physical copy. A small fee may be charged for providing a copy of health information.

Right to Correct Errors in Your Health Records After obtaining and checking your health records, you may discover an error such as an allergy that has not been recorded. HIPAA gives patients the right to make changes to their health information to correct mistakes. Any request to change a health record must be submitted in writing.

Right to Find Out Who Has Received Your Health Data HIPAA includes a right to an accounting of disclosures of health data. If requested, a covered entity is required to provide information about who has received an individual's health data over the past six years.

Right to Restrict Sharing of your Health Data Patients/clients have the right to restrict sharing of their health data for certain purposes other than treatment, payment, or healthcare operations. HIPAA covered entities are not permitted to sell your health data or use it for marketing, advertising, or research, without first obtaining authorization to do SO in writing.

Patients can also dictate to whom their health information can be shared, such as family members, friends, caregivers, legal representatives, or other entities. They can also request that information is not shared with other individuals or groups.

Right to File a Complaint for a Privacy Violation If you believe your health data has been accessed by an unauthorized individual, has been impermissibly disclosed, or you believe that any aspect of HIPAA Rules has been violated, you have the right to file a

complaint. It is also possible to file a complaint if patient rights under HIPAA have been denied. The Department of Health and Human Services' Office for Civil Rights (OCR) investigates complaints. If OCR determines that HIPAA Rules have been violated, fines can be issued for noncompliance. HIPAA does not have a private cause of action, which means that it is not possible for an individual to take legal action against a HIPAA-covered entity or business associate for a privacy breach or HIPAA Rule violation.

*Please complete Release of information if records or communication to or from NNPA is required. Also complete if client is over age 18 and consents to parents receiving communication from NNPA clinicians and administration for treatment and billing issues.*

Release of Information Consent Form Craig Clark, M.D., Amy Powell, MA LPE, Justin Malais, PMHNP Alyssa Mielock PhD(post-doc) Tim Caldwell LPC/MHSP(temp)

2. I AUTHORIZE Nashville Neuro Psychiatric Associates; Phone: 629-203-6779 Fax: 615-678-1916

exchange information with the person/organization in section 3.

3. ORGANIZATION / INDIVIDUAL INFORMATION / Organization Name:

4. INFORMATION TO BE RELEASED Specific dates/years of treatment:

All health information (excludes information from a chemical dependency program & psychotherapy notes) OR indicate the specific categories to be released:DiagnosisPsychological Evaluations School/Criminal Provider/Hospital RecordsRecordsOther: Discharge Summary Treatment Plans Social History

Legal/Court Order Personal Request

6. I UNDERSTAND THAT: My health information is protected by federal regulation (Alcohol & Drug Abuse Patient Records, 42 CFR Part 2; and/or HIPAA 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances described in Privacy Notice. I can revoke this authorization at any time except to the extent that action has been taken in reliance on it. Nashville Neuro Psychiatric Associates outlines the procedure for revocation. This authorization will expire in one year from the date | sign or unless request an earlier expiration in writing.For disclosures other than for treatment, payment and healthcare operations purposes, treatment may not be conditioned on my agreement to sign and authorization (unless I am receiving care solely to create protected health information for disclosure to a third party Communications resulting from this authorization will reveal that I receive services at NNPA. Federal confidentiality regulations (42 CFR Part 2) prohibit re-disclosure of information from alcohol & drug abuse patient records. However, HIPAA requires NNPA to notify me of the potential that information disclosed pursuant to this authorization might be re-disclosed by the recipient and is no longer protected by HIPAA.

7. SIGNATURE Patient's Signature: