Adult Consents

Please read through all the below forms carefully. Your signature will be required at the end, to confirm your agreement to all the included terms.

 

 

1. Policies

Please read the below Policies document carefully, in its entirety. Your agreement to the following terms and conditions is required for you/your child to receive professional services from me.

If you do not agree, I will be glad to give you referrals to other providers.

Clinical services

• Appointments may be held in person or virtually, as agreed upon in advance. The link for all virtual appointments is https://doxy.me/drvarblow 
• You consent for yourself/your child to receive an initial consultation. At the end of the session, we will mutually decide if we will contnue treatment together.
•  If, at any time, there is a potential of any physical danger to you, your child, or others, you will call 911 immediately or go to the closest emergency room.
• To reach me outside of standard business hours, you may leave me a message through the patient portal, email me at drkarin@drkarinmd.com, or you may leave a voicemail at (703) 996-4737. I will respond to your message as soon as possible, usually the following business day. Note that messages are not retrieved on weekends, federal holidays, or after 4:30PM on weekdays.
• Messages will be used ONLY for the purposes of scheduling and rescheduling appointments, and medication refill requests. Clinical advice may not be provided through messaging.
• Note that I am a pediatrician, not a psychiatrist, and I do not have hospital admitting privileges. Should I deem more intensive services are needed than I can provide, I will do my best to ensure safety and obtain the appropriate level of care, but I cannot provide that care directly and cannot guarantee the receipt or quality of care that others provide.
• All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. I will be happy to provide the records to any professionals of your choice or to prepare an appropriate summary, as requested. Because client records are professional documents, they can be misinterpreted and can be upseting for individuals to access. If you wish to see the records, it is best to review them with me so that we can discuss their content.

 

 Confidentiality

• Confidentiality is maintained in accordance with accepted ethical standards.
• There is no guarantee of confidentiality under the following conditions:

-If I suspect you/your child are/is in imminent danger of harm to self or others, or a child or elderly person is being abused or neglected (as I am a mandated reporter)

-If a court orders a release of information -If you initiate a malpractice lawsuit, or a billing dispute with a financial institution

-If your insurance company requests to review your/your child’s case

-If you pay by credit card, my name will appear on your credit card statement

-If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collection agency or other responsible party

-Between me and my administrative staff, or colleagues with whom I consult professionally

• You confirm you have reviewed my HIPAA privacy practices in the form entitled "Notice of Privacy Practices."

 

Payment

• All fees must be paid at the time of service. To ensure timely payments, every Patient and/or Patient's Guarantor MUST provide credit card information, to be stored securely, to cover current and future payment obligations. 
• You agree to pay professional fees as follows:

Initial, 90-minute Consultation: $900

Follow-Up Visit, 45 minutes: $450

• You will be charged the full amount for any appointments that are missed, cancelled, or rescheduled with less than 2 full business days’ notice. For example, if you or your child’s appointment is on Monday at 4pm, you will communicate your cancellation no later than the previous Thursday at 4pm; if an appointment is on Tuesday at 10am, you will communicate no later than Friday at 10am.
• You agree to pay for anytime spent on your or your child's care outside of appointment time, on a pro-rated basis. Unfortunately, insurance companies typically do not reimburse for this. Some examples include, but are not limited to:

-Phone calls, messages in the patient portal, voicemails, letters, video sessions and texts between me and: you, your child, or other physicians, therapists, teachers, family members, insurance companies, etc.

-Prescription refills outside of session time

-Time spent obtaining prior authorizations

-Coordination of care for emergencies, hospitalization, intensive outpatient, residential treatment, rehabilitation, etc.

-All forms (insurance, worker’s compensation, school, employer; doctor’s notes, letters, or reports) and chart reviews not filled out in session

-Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority

• If your credit card is declined for any reason, and payment is delayed beyond a 30-day period from the time of service, a $35 fee will be added to your account. Your account will subsequently be charged $35 for each additional 30-day period that the service fees are not paid in full.
• You are financially responsible for all charges, whether or not:

-Insurance pays for any services

-We decide to proceed with treatment

-Treatment is successful, for which there cannot be any guarantee

• You affirm you are an authorized user of the credit card whose number and expiration date you supplied, and you do authorize its use for all fees incurred.

 

 

2. Medicare Waiver

Dr. Varblow does not participate in Medicare in the state of Virginia. You acknowledge that you have been informed that she is not a Medicare provider and that you are responsible for all fees for her services. You also agree not to submit a claim to Medicare or ask Dr. Varblow to submit any claims to Medicare.

3. Consent to Treatment and Services

The below document includes important information about my professional practice, service procedures and business guidelines. When you sign this document, it will represent an agreement between us.

You may revoke this agreement in writing anytime.

Please read this carefully and discuss any questions or concerns that you may have.

Sessions and Fees

• Initial visits are for 1 hour and 30 minutes and are $900. Thereafter, all visits are scheduled for forty-five minutes and the fee per session is $450.
• Payment is collected at the time of service via a securely held credit card, unless other arrangements have been made in advance.
• In addition to scheduled appointments, a fee will be charged for my attendance at appointments by phone or other media; meetings with other individuals, such as therapists, physicians, counselors, family members, or others, as requested by you; scoring of tests; and written reports/letters/communication with other professionals or individuals (all with explicit written consent).
• All fees are subject to change and will be reviewed and updated periodically.
• I will provide you with an emailed receipt after each visit, which you may submit to your insurance company for reimbursement. I do not submit any paperwork directly to insurance companies, and I am not “in network” for any insurance providers. That said, some insurance companies do provide reimbursement for my services at an “out-of-network” rate.
• Services such as school observations, attendance at meetings, and written reports and other communication are entirely optional, and they are rarely reimbursed by insurance companies.
• Because your scheduled appointment time is reserved for you, you will be charged for missed or cancelled sessions when there is less than 2 business days' advance notice. Please understand that most insurance companies will not cover charges for missed sessions. Nonpayment of fees may result in fee collection procedures.

 

Confidentiality

Confidentiality is maintained in accordance with accepted ethical standards. Written authorization is required for any release of information or records, except under the following conditions: disclosure is required by law, court order, imminent danger to self or other, suspicion of child abuse or neglect, and/ or nonpayment of fees (only billing information will be provided to a collection agency).

 

 

 

HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) requires that I provide you with a Notice of Privacy Practices for use and disclosure of specific health care information. The Notice of Privacy explains HIPAA and its application to your personal health information in greater detail. Your signature below serves as your acknowledgement of receipt of the Notice of Privacy Practices and consent to the HIPAA guidelines.

 

Availability and Emergency Procedures

Please call (703) 996-4737 to contact me by phone. I check my messages regularly. Every effort will be made to return your call within 24 hours, with the exception of weekends and holidays/vacations. Your primary care provider is generally another excellent resource, as needed. In the case of a clinical emergency, please contact me and report to the police (911) and/or the Emergency Room of the nearest hospital.

I may also be available to communicate with you via cell phone and email, but please note that these means of technology offer no guarantee of confidentiality. Our use of these technologies implies that you recognize that they are not necessarily HIPPA-compliant and that you consent to communication via those avenues, regardless. I do NOT communicate with patients or families via text.

4. Stimulant Medication Contract

Many of the medications used to treat Attention Deficit/Hyperactivity Disorder (ADHD) are stimulants, which are classified by the FDA as Controlled Substances, due to the potential for them to be abused and misused, and because they can be dangerous if not taken as directed.

This agreement is intended to prevent misunderstandings about stimulant medicines you or your child have been prescribed, and to help both providers and patients comply with the laws regarding controlled pharmaceuticals. Failure to comply with this agreement may result in the discontinuation of your prescription and/or dismissing you from this medical practice.

Patients (and their families) agree to:

• Make an appointment to be seen at least once every 90 days. Prescriptions can only legally be provided when the patient has been seen by the doctor within the past 90 days, and no more than 90 days’ worth of medication can be prescribed between visits. 
• Receive prescriptions for stimulant medication only from this office while you are a patient here.
• Not use any illegal substances, including marijuana or other “recreational drugs,” and not abuse alcohol.
• Not share, sell, or trade medications with anyone.
• Safeguard medication from loss or theft. Lost or stolen medicine cannot be replaced.
• Understand that prescriptions may not be available on weekends or on short notice.
• Provide at least 7 days’ advance notification when a new prescription is needed. Refills can not be provided automatically for any Controlled Substance, and prescriptions can only be written for 30 or 90 days at a time. The exact number of days is determined by your insurance company.
• Use medicine only as prescribed, without increasing the dose or frequency of medicine without consulting the provider.
• Inform your health care provider about any other medications you are taking.
• Recognize that it is the policy of this practice to cooperate fully with any city, state, or federal law enforcement agency in the investigation of any misuse, sale, or other diversion of a prescription.

 

 

5. Consent to Telemedicine Consultation

• I understand that my health care provider may wish that I engage in telemedicine consultation.
• I understand that visiting my healthcare provider through telemedicine technology means that I will not be in the same room with my provider.
• I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties, and I am aware that my provider or I can discontinue the telemedicine visit if it is felt that the videoconferencing connections or settings are not adequate for the situation.
• I understand that billing will occur from my healthcare provider as if the visit were held in person in the office setting. All pre-established policies regarding cancellation and payment at the time of the appointment remain in effect. Specifically, cancellations must be made with at least 2 business days’ advance notice, or the patient will be charged the full price of the visit.
• I understand that telehealth is considered a scheduled outpatient appointment, and I should call 911 or go to the nearest Emergency Department in the case of a medical emergency.
• I agree to be within the boundaries of the state of Virginia during telemedicine visits, so that I am in the jurisdiction in which Dr. Varblow is licensed to practice medicine.
• I have had the opportunity to ask questions about this procedure, and my questions have been answered. The risks, benefits, and any practical alternatives have been discussed with me in a language which I understand.

 

 

 

6. Consent to Email Communication

• I consent to receive emails from Dr. Varblow at the email address provided above. Email may be used to arrange for appointments or to answer questions posed to the doctor between in-person visits.
• I understand that the email system utilized by Dr. Varblow is may not be associated with a HIPAA-compliant, secure patient portal system, and, as such, it may not offer any more security than any other regular email system.
• I understand that I am not required to provide this consent in order to receive healthcare services from Dr. Varblow.
• I understand that I have the right to revoke this consent using any reasonable method including orally or in writing.

 

 

 

 

7. NO SURPRISES ACT

As part of the "No Surprises Act" which went into effect January 1, 2022, out-of-network providers are required to provide patients a "Good Faith Estimate" of their treatment costs.The purpose of this document is to let you know about your protections from unexpected medical bills. 

The fees for services provided by Dr. Karin Varblow, MD, are as follows:

• Initial, 90 minute consultation for a new patient: $900
• Follow-up visit, 45 minutes: $450
• All services provided on behalf of you or your child will be prorated, at the base of $600 per hour.
• Please see the POLICIES document for examples of out-of-session services.

 

Frequency of Appointments:

• After the initial consultation, appointments may be scheduled approximately once every 2-4 weeks, depending on symptom severity and the needs of the patient and/or family.
• As symptoms improve and needs decrease, appointment frequency may be reduced, but all patients MUST be seen AT LEAST EVERY 90 DAYS for RX access.
• Whenever medication doses are changed, frequency of visits may increase to allow for patient monitoring.

 

 

 

 

8. Notice of Privacy Practices

This Notice describes how health information about you may be used and disclosed and how you can get access to this information. This Notice provides you with information to protect the privacy of your confidential health care information, hereafter referred to as protected health information (PHI). The Notice also describes the privacy rights you have and how you can exercise those rights. Please review it carefully.

If you have any questions about this Notice, please contact me at your convenience.

This Notice is effective as of 09/01/2013.

 

MY OBLIGATIONS

I am required by law to:

• Maintain the privacy of protected health information
• Give you this notice of my legal duties and privacy practices regarding health information about you
• Follow the terms of this notice that is currently in effect

 

HOW I MAY USE AND DISCLOSE HEALTH INFORMATION

The following describes the ways I may use and disclose health information that identifies you (“Health Information”). Except for the purposes described below, I will use and disclose Health Information only with your written permission. You may revoke such permission at any time, in writing.

For Treatment. I may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, I may disclose Health Information to doctors, nurses, technicians, or other personnel, who are involved in your medical care and need the information to provide you with medical care.

For Payment. I may use and disclose Health Information so that I or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, I may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. I may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all patients receive quality care and to operate and manage this office. I also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. I may use and disclose Health Information to contact you to remind you that you have an appointment. I also may use and disclose Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care. When appropriate, I may share Health Information with a person who is involved in your medical care or payment for your care, such as your family. I also may notify your family about your location or general condition or disclose such information an entity assisting in a disaster relief effort.

 

SPECIAL SITUATIONS

As Required by Law. I will disclose Health Information when required to do so by  international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. I may use and  disclose Health Information when necessary to prevent a serious threat to your safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.

Business Associates. I may disclose Health Information to our business associates that perform functions on my behalf or provide me with services, if the information is necessary for such functions or services. For example, I may use another company to perform billing services. All of my  business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Organ and Tissue Donation. If you are an organ donor, I may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the armed forces, I may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

Public Health Risks. I may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. I will only make the disclosure if you agree or when required or authorized by law.

Health Oversight Activities. I may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and for licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Data Breach Notification Purposes. I may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your health information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, I may disclose Health Information in response to a court or administrative order. I also may disclose Health Information in response to a subpoena, a discovery or other lawful process by someone else involved in the dispute, but only if the efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. I may release Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person(3) about the victim of a crime even if, under certain very limited circumstances, I am unable to obtain the person’s agreement; (4) about a death I believe may be the result of criminal conduct; (5) about criminal conduct on my premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

 

USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT

Individuals Involved in Your Care or Payment for Your Care. Unless you object, I may disclose to a member of your family, a relative, a close friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, I may disclose such information as necessary if I determine that it is in your best interest based on my professional judgment.

Disaster Relief. I may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. I will provide you with an opportunity to agree or object to such a disclosure whenever I practically can do so.

YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to me will be made only with your written authorization. If you do give me an authorization, you may revoke it at any time by submitting a written revocation and I will no longer disclose Protected Health Information under the authorization. But disclosure that I made in reliance on your authorization before you revoked it will not be affected by the revocation.

YOUR RIGHTS

You have the following rights regarding Health Information I have about you:

Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Health Information, you must make your request, in writing. I have up to 30 days to make your Protected Health Information available to you and I may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. I may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state of federal needs-based benefit program. I may deny your request in certain limited circumstances. If I do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and I will comply with the outcome of the review.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. I will make every effort to provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either my standard electronic format or if you do not want this form or format, a readable hard copy form. I may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Amend. If you feel that Health Information I have is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is kept by or for my office. To request an amendment, you must make your request in writing.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

 

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with my office or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint.

Karin Varblow, MD, PC

1489 Chain Bridge Rd, #203

McLean, VA 22101

703-996-4737

 

 By signing below, I certify that:

• I have read the above documents and/or had them explained to me
• I fully understand the terms, procedures, and guidelines outlined
  therein
• I have been given ample opportunity to ask questions and any
  questions have been answered to my satisfaction
• I have received a copy of the HIPAA regulations, if requested
• I am the patient or the patient’s legal representative