Clearwave Spravato New Patient Registration Forms

Independent Contractor Physicians

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

• Inner Healing Integrative Psychiatry, PLLC, which is owned and operated by Kimberly Robinson, MD.
• Arborview NP in Psychiatry PLLC, which is owned and operated by Manpreet Nijjar,
• Dr. Griffan Randall D.O. PLLC, which is owned and operated by Griffan Randall D.O., ABPN

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

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

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

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

To the extent an initial treatment session is scheduled, upon commencing my first treatment session, I agree and consent to participation in the health care services offered and provided by Clearwave, Inner Healing Integrative Psychiatry, PLLC, Arborview NP in Psychiatry PLLC, or Dr. Griffan Randall D.O. PLLC. I understand that I am consenting and agreeing only to those services that the above provider is qualified to provide within the scope of the license, certification, and training of the health care providers directly supervising the services received by the patient.

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

I have read and understand the above statement:

Notice Of Privacy Practices

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

Clearwave Spravato Financial Policy

Charges for Spravato (Esketamine) Therapy:

1.Spravato (Esketamine) ("Spravato") therapy is provided by TMS Medical of the Hudson Valley, P.C. d/b/a Clearwave TMS Medical ("Clearwave TMS" Clearwave TMS's standard fee schedule is as follows:

• Small Dose (56 mg) - $1,800.00 per unit
• Large Dose (84 mg) - $2,300.00 per unit

2. The typical course of treatment for Spravato is twice per week for the first four weeks, followed by once per week for four weeks, followed by either weekly or bi-weekly treatments.

Insurance Coverage for Spravato Therapy:

1. Many insurers provide coverage for Spravato therapy based on specific conditions and treatmentprotocols and often require prior authorization before beginning treatment. While our team can assist in obtaining prior authorization for treatment and can assist with obtaining an estimate for the out-of-pocket cost of coverage, it is ultimately your responsibility to verify insurance benefits and determine if you have coverage based on your diagnosis and particular benefit plan and how much treatment will cost you out of pocket. Please be aware thatauthorization only determines that the requested service is medically necessary and does not guarantee payment of benefits or that your insurance will pay the full amount of Clearwave TMS's charges. Payment is also subject to the terms of your health plan at the time services are delivered and benefit limitations and/or exclusions. Moreover, if your health plan later determines that treatment was not medically necessary, you will be responsible for any amounts denied by your health plan. Any estimates provided by Clearwave TMS for your out-of-pocket costs are only provided as a courtesy and Clearwave TMS cannot guarantee that the estimated out-of-pocket cost will be equal to amount you actually owe under your insurance plan. You are responsible for all Clearwave TMS charges for your care.

2. To the extent Clearwave TMS has reached an agreement with your insurance company regarding your treatment - either because Clearwave TMS is in-network with your insurance company or because Clearwave TMS has reached a separate agreement regarding your TMS treatment - you hereby authorize Clearwave TMS to bill your insurance company for those services and for your insurance company to pay such sums directly to Clearwave TMS. If your insurance company remits such payment to you directly, you shall redirect such payment to Clearwave TMS as soon as possible.

3. For self-pay, out-of-network, and off-label care, payment is due in full at the time of the initial course of therapy. If your insurance carrier approves coverage of Spravato therapy, we will collect any copayments, coinsurance and deductibles required under your insurance plan based on ouractual charges. Please be aware that our charge to insurance may differ from our charge for self-pay patients and the amount your insurance company approves may differ from our actual charge. You are responsible for payment of our actual charge. 

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

Cancellation Policy

1. In order for Spravato therapy to be effective, it should be performed on a routine basis for the complete treatment protocol. For self-pay patients, we will refund payment ONLY if we receive notice of cancellation at least seven (7) days before the date your initial (acute phase) treatment is scheduled to begin. No refunds will be given within seven (7) days before you are scheduled to start the initial, acute phase, treatment block.

2. Missing any treatment could affect your response to Spravato and is not advisable. If you fail to cancel a particular day's Spravato treatment within 24 hours of that treatment, you will be charged a cancelation fee of $50.00. Clearwave TMS, in its sole discretion, may choose to waive or reduce this cancellation fee, however, any waiver or reduction in cancellation fee shall not be deemed a change in the Cancellation Policy and Clearwave TMS reserves the right to enforce its Cancellation Policy on all subsequent missed treatments. Please be advised that most insurance companies do not reimburse for missed appointments and therefore you will likely be personally responsible for any assessed cancellation fee.

Payment Requirements

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

2. The patient is ultimately responsible for payment for Spravato therapy. We accept most forms of payment. Payment for Spravato therapy should be made to TMS Medical of the Hudson Valley, P.C. Returned checks will becharged the entire amount plus a $25 return check fee. Late payments will be charged interest at the rate of 1% per whole or partial month the payment is overdue, or 5% of the total bill, whichever is greater. 

3. If you fail to timely make required payments, Clearwave TMS reserves the right to pursue any and all means to collect outstanding payments. If Clearwave TMS incurs any attorneys' fees and costs in its collections efforts, you shall be responsible for reimbursing 1 Clearwave TMS for all attorneys' fees and costs incurred to the extent permitted by law.

Patient Acknowledgement

I acknowledge I have read this document and have been given an opportunity to ask questions. My questionshave been answered to my satisfaction. A copy of this form has been made available

Authorization to Disclose Medical Records or Health Information:

Charges for Forms:

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

Credit Card Authorization Form

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

Medicare Private Contract - Provisions for Dr. Pardell and Dr. Randall

 

Introduction - While TMS Medical of the Hudson Valley, PC d/b/a Clearwave TMS Medical (“Clearwave”) participates with Medicare, there are certain individual providers who provide clinical services on behalf of Clearwave who are not participating providers with Medicare. Accordingly, this Medicare Private Contract and the following Medicaid/Medicare Private Contract pertains to any patient who treats with the following providers:

Randy I. Pardell MD
Griffan Randall, DO of Dr. Griffan Randall D.O. PLLC
 

Background

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

 

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

 

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

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

Exception:

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

Obligations of PhysicianPhysician agrees to provide such treatment as may be mutually agreed upon by the parties and at mutually agreed upon fees.
Physician agrees not to submit any claims under the Medicare program for any items or services even if such items or services are otherwise covered by Medicare.
Physician acknowledges that (s)he will not execute this contract at a time when the patient is facing an emergency or urgent health care situation.
Obligations of PatientPatient or his/her legal authorized representative agrees not to submit a claim (or to request that the physician submit a claim) under the Medicare program for such items or services as physician may provide, even if such items or services are otherwise covered under the Medicare program.
Patient or his/her legal authorized representative agrees to be responsible, whether through insurance or otherwise, for payment of such items or services and understands that no reimbursement will be provided under the Medicare program for such items or services.
Patient or his/her legal authorized representative acknowledges that that Medicare limits do not apply to what the physician/practitioner may charge for items or services furnished by the physician/practitioner.
Patient acknowledges that Medigap plans do not, and other supplemental insurance plans may elect not to, make payments for items and services not paid for by Medicare.
Patient acknowledges that (s)he has the right to obtain Medicare‐covered items and services from physicians and practitioners who have not opted out of Medicare, and that the (s)he is not compelled to enter into private contracts that apply to other
Medicare covered services furnished by other physicians or practitioners who have not opted out.
Patient acknowledges that (s)he or his/her legal representative understands that Medicare payment will not be made for any items or services furnished by the physician/practitioner that would have otherwise been covered by Medicare if there were no private contract and a proper Medicare claim had been submitted.
Physician’s Status - Patient further acknowledges his/her understanding that physician (has/ has not) been excluded from participation under the Medicare program under Section 1128.
Term and Termination - This agreement shall commence on the above date and shall continue in effect until  (physician should insert date which is two [2] years after [s]he signs the affidavit). Despite the term of the agreement, either party may choose to terminate treatment with reasonable notice to the other party. Notwithstanding this right to terminate treatment, both physician and patient agree that the obligation not to pursue Medicare reimbursement, for items and services provided under this contract, shall survive this contract.
I have read and understand the provisions regarding private contracting.

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

Informed Consent for the Use of AI Scribe Service
 
This document is an informed consent form designed to ensure that you fully understand and consent to the use of AI scribe services during your medical encounter with Riverview Psychiatric Medicine PC d/b/a Clearwave Psychiatry and TMS Medical of the Hudson Valley PC d/b/a Clearwave TMS Medical (collectively, “Clearwave”). 
 
Description of AI Scribe Services: AI scribe (e.g. Freed) services uses the microphone on a secure smartphone to transcribes—but not record—patient encounters and then uses machine learning and natural-language processing to summarize the conversation's clinical content and produce a note documenting the visit. The AI scribe services with which Clearwave contracts uses technology that is HIPAA-compliant and maintains robust systems to protect all PHI. 
 
Purpose and Benefits of Remote Scribe Services: The purpose of AI scribing is to improve the efficiency of your medical encounter by allowing your healthcare provider to focus on patient care while ensuring accurate documentation of the encounter for quality assurance and billing purposes. AI scribing will allow your provider to be even more engaged during your session without the need to continuously document the encounter. 
 
Confidentiality and Privacy: Your privacy and the confidentiality of your medical information are of the utmost importance. AI scribe services with which Clearwave contracts adheres to strict confidentiality guidelines. All information transmitted during the encounter will be encrypted to protect your privacy. In the unlikely event that the AI scribe service suffers a data breach that impacts you, you agree that you will not hold Clearwave or its respective officers, directors, managers, employees, contractors and agents liable for any such breach. 

Voluntary Participation: Participation in AI scribe services is entirely voluntary. You have the right to refuse the use of AI scribe services at any time during your medical encounter. 
 
By signing below, you acknowledge that you have read and understood the information provided in this document, and you voluntarily consent to the use of AI scribe services during your medical encounter. 

DISCLOSURE OF FINANCIAL ARRANGEMENT

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

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

If you were referred to Clearwave Psychiatry or Clearwave TMS from a provider who owns, is employed by, or contracts with one of these entities, please be advised that you are under no obligation to treat with the referring provider or any other provider at Clearwave Psychiatry or Clearwave TMS. To the extent you wish to explore mental health treatment, you are entitled to seek an alternative provider at another facility. For a list of some of the medical providers within 50 miles of any of our office locations, you may click here, or you may ask our staff to provide you with names and addresses of providers best suited to your individual needs that are nearest to your home or place of work. By signing below, you acknowledge that you understand the nature of the financial relationship between Clearwave Psychiatry and Clearwave TMS and that you have your choice in mental health treatment providers and, should you choose to treat with Clearwave Psychiatry or Clearwave TMS, you are choosing to do SO without influence.

HealtheConnections Consent Form

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

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

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

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