CONSENT FOR PSYCHIATRIC SERVICES/PRACTICE POLICIES
Welcome to Doxa Health and Wellness LLC. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. When you sign this document, it will also represent an agreement between us. We can discuss any questions you have when you sign them or at any time in the future.
INITIAL EVALUATION & SESSIONS
Our Clinicians generally conduct a thorough psychiatric evaluation during the initial session – which is typically scheduled for 60 minutes. This assessment focuses on determining the best treatment plan possible and is specific to each individual patient. It is extremely important for this initial assessment to be as comprehensive as possible. Therefore, please provide completed patient forms prior to your appointment and make sure to provide information about previous providers, past psychiatric treatment, and medication trials. In some situations, extra sessions are needed to complete an appropriate evaluation. Additionally, collateral information (i.e., school reports, family reports, etc.) are often necessary for children and adolescents – and helpful for adult patients as well. These issues will be discussed during the initial session. Please remember that a comprehensive assessment is necessary regardless of the treatment modality (i.e., psychotherapy, psychiatric medications, or both) as it allows us to provide the best possible care.
PRACTICE STATUS
Doxa Health and Wellness LLC is an integrated practice of mental health providers. At any time, there may be several mental health professionals that work in this office suite. While we share space and often provide collaborative care, each provider is responsible for providing care up to professional standards. All records are stored using an electronic health record system. Your records should only be accessed by your current provider as well as covering providers. The office assistant also may, at times, have access to your record. Please note that it is our policy to always protect this information in accordance with all legal and ethical standards.
MEDICATION MANAGEMENT & PSYCHOTHERAPY
At Doxa Health and Wellness LLC, we believe that sometimes one may need medication to help achieve their behavioral health goals. It is important that medication is monitored, and ongoing discussion occurs with a licensed professional to ensure the right medication and treatment plan is implemented. Our clinicians may include brief psychotherapy during the initial evaluation or medication management visits. Sole therapy sessions are currently offered at our practice. If a referral is necessary, this will be discussed in session and your provider may provide referrals to a therapist and collaborate with these professionals. Please note we cannot be responsible for the services/treatment that they provide. It is always your responsibility to determine if a professional referral is acceptable.
PROFESSIONAL FEES
Our practice is committed to providing the best treatment for our patients and we charge usual and customary rates. If you choose to pay as a private payer, our fees are as follows: New patient initial evaluation up to 60 minutes: $250; Each medication management (Follow-Up) up to 30 minutes: $150; Medication management with psychotherapy up to 40 minutes: $200. Please note: There will be a charge of $250 for filling out any paperwork (i.e., FMLA or Disability form).
We do not provide any forensic services. As such, court proceedings (even if required to testify by another party) are currently billed at an hourly rate of $250 per hour for our Clinicians. Moreover, the hourly rate for any out-of-office proceedings (including depositions and court hearings) are based on the number of patient hours cancelled to provide this service, even in a situation in which our testimony is required by another party including a court of law.
Please note that our fee schedule is subject to change over time and will be updated on an ongoing basis. Any and all services requested will be at the discretion of your provider.
REGARDING INSURANCE
Your insurance coverage is a contract between you and your insurance company. If we are a contracted provider with your insurance company, we will handle your claims according to our agreement with your particular insurance company. As a courtesy to you, we are happy to file your primary and secondary insurance. If you have more than two insurance companies, you will be responsible for filing the third insurance. Even though you have insurance, some diagnoses may not be covered under your insurance plan. If this occurs, you are responsible for the full fee for services.
Our office cannot guarantee insurance coverage for services provided. Questions about insurance payment and/or coverage should be directed to the insurance company.
By signing this form, you are authorizing your insurance benefits to be paid directly to the provider Doxa Health and Wellness LLC and the insurance company may release information required to process your claims.
You are responsible for paying all deductible, co- payments, co-insurance, fees and any non-covered services in full at the time of service.
In the event we accept assignment of benefits, you are still ultimately responsible for all charges. We will not become involved in disputes with your insurance company. If your insurance providers have not provided payment within 45 days, we will expect payment from you.
BILLING AND PAYMENT
Payment for each clinical session and/or service is due prior to each appointment. Additionally, payment for all other professional services will be addressed at the time of your request for such services. Please discuss any billing or payment concerns with your provider as this is an important part of the clinical process.
We accept all major credit cards (MasterCard, Visa, American Express, and Discover) for all professional services. Please always inform us immediately if your credit card is replaced or renewed with another card. If your account is overdue for more than 30 days, we reserve the right to assess a penalty of $50 per 30 days overdue, and potentially use legal means to secure payment. This includes charging a credit card on file and/or utilizing a collections agency or a small claims court. In such cases, certain information may be required by these agencies. This can include name, nature of services provided, clinical notes, and amount due. It is always your responsibility to keep the credit card on file up to date with your clinician and our administrative staff. As such, our clinic policy is to require an active credit card on file in order to keep your chart open. In instances when a credit card charge is disputed, we may need to provide personal and clinical information to your credit card company.
Please be aware that if your outstanding balance exceeds $150 we will not be able to schedule further appointments until the balance is paid. Outstanding balances may be forwarded to a collection agency after 90 days of non-payment.
In signing this form, you authorize Doxa Health and Wellness LLC to bill and seek payment from third-party payers on your behalf. In addition, if insurance denies coverage or payment for any reason, you remain responsible for paying any outstanding balance.
NO SHOW/LATE ARRIVAL POLICY
Our goal is to provide quality individualized psychiatric care in a timely manner. No-shows, late arrivals, and same-day cancellations inconvenience those individuals who need access to mental health care. As a courtesy, if you need to change or cancel an appointment please notify us at least 24 hours in advance. You may be charged $50 for not showing up to an appointment or cancelling with less than 24 hour notice. Patients who no-show or late cancel two or more times in a 12-month period, may be asked to seek services elsewhere. We understand that delays can happen. That said, we must try to keep the other patients and families on time. If you arrive more than 15 minutes past your scheduled appointment time, you may be charged $50 for a late appointment fee and we may have to ask you to reschedule.
PARENTS/GUARDIANS OF MINORS RECEIVING SERVICES
You are required to be present during initial and follow-up medication management appointments. This allows the clinician to review/update the treatment plan and address any questions.
POLICY OF STUDENTS RECEIVING SERVICES
Our psychiatric clinic welcomes students as clients and is committed to providing accessible and high-quality mental health care to support their well-being. We provide services to students of all educational levels, including elementary, middle, high school, and college/university students. A parent or legal guardian must provide consent for treatment if the student is under 18, unless otherwise permitted by state law. Students over the age of 18 may consent to their own treatment.
METHODS OF CONTACT
On occasion, there may be times where you need to contact a clinician outside of a scheduled appointment. Please call our office number. If we are not available to take your call or if it is after hours, please leave a message and someone will get back to you within 1-2 business days. If a situation is an emergency, such as an individual is a risk/danger to oneself or others and cannot remain safe, go to the nearest ER or call 911.
When your provider is unavailable for extended periods of time (i.e., vacation, conferences, etc.), a trusted colleague will provide coverage. The covering provider will also have access to your medical records so that they can provide the highest level of care possible.
In addition to calling our office, you can also contact us through your patient portal (i.e., to schedule appointments, complete forms, send messages etc.).
MEDICATION REFILLS
You are required to be present during initial and follow-up medication management appointments. This allows the clinician to review/update the treatment plan and address any questions.
PROFESSIONAL RECORDS
All records are currently stored using an electronic health record system. At Doxa Health and Wellness LLC, your records will only be accessed by your current provider, a covering provider during periods requiring coverage, or by our administrative staff as needed. It is our policy to always protect this information in accordance with all legal and ethical standards. Our electronic health record system also has access to your records as regulated by federal law. Although you are generally entitled to a copy of your records, they can be misinterpreted given their professional nature. In instances when it is deemed potentially damaging to provide you with the full records, these records are available to be sent to an appropriate mental health professional of your choice. Alternatively, we can review them together and/or treatment summaries can be provided. Please note that professional fees will be charged for any preparation time required to comply with such requests. All records requests should be sent directly to your provider with a signed release of information form filled out and attached.
RELEASE OF INFORMATION
Information will not be released without a signed release of information. Please fill out a release of information form for any individual or agency that you would like involved in your care. Any paperwork or correspondence that you need completed will require a signed release of information. If an individual is hospitalized, coordination of care is essential to ensure the best outcome. Therefore, multidisciplinary staff will be allowed to schedule follow-up appointments to assist with coordination of care. No personal health information will be shared without release of information.
CONFIDENTIALITY
Confidentiality is a cornerstone of mental health treatment and is protected by law. Aside from emergency situations, information can only be released about your care with your written permission (or written permission from your legal guardian(s) for those under 18). If insurance reimbursement is pursued, insurance companies often require information about diagnosis, treatment, and other important information as a condition of your coverage.
We understand that the information you share can be very personal and by signing this consent for psychiatric services, you acknowledge receipt of the Notice of Privacy Practices.
Staff at Doxa Health and Wellness LLC are required to hold information about sessions and clients in confidence and are not allowed to disclose such information without the expressed written consent of all those involved in treatment, except in the following circumstances:
There is clear and imminent danger to you or others in which case the clinician may be required to inform the responsible authorities and warn the identified victim. If this occurs, the clinician may inform you of their responsibilities and actions.
In situations of suspected physical, emotional, or sexual abuse of a child, or dependent adult abuse, clinicians are required to submit a report to the Department of Human Services and may be required to contact authorities. Again, in this situation you may be informed of the clinician’s responsibilities and actions.
Doxa Health and Wellness LLC maintains records of treatment, diagnosis, assessment, and treatment planning in accordance with state law, and to better guide your treatment and assess the effectiveness of treatment provided. You may request restrictions as to how your case information may be used or shared among staff of the group practice, but Doxa Health and Wellness LLC is not required to agree to those restrictions.
If the release of information is mandated by law. Some litigation may require the release of records even without the client’s authorization. Clinicians will not typically testify in court as this creates an irreconcilable role conflict that harms the therapeutic relationship.
We reserve the right to consult with other professionals, whether within our practice or with an outside professional that may have a specialized knowledge in a certain area. In these circumstances, your identity will not be revealed, and only necessary clinical information will be discussed. Please note that such consultants are also legally bound to keep this information confidential.
ELECTRONIC MAIL (EMAIL) & TEXTING
Our practice has safeguards in place to help ensure that email and text communications remain HIPAA compliant. However, email and text messaging are not fully secure methods of communication, as they can still be intercepted, accessed by unintended recipients, or compromised.
For this reason, email and texting should not be used for sharing clinical information, confidential matters, or urgent concerns. If you choose to email clinical information to your provider, they may request that you schedule an appointment or a phone call instead.
We cannot guarantee that email or text messages will be received or responded to in a timely manner. By choosing to communicate via these methods, you acknowledge and accept the inherent confidentiality risks, including potential unauthorized access to your messages and any responses from your provider or our staff.
To prioritize confidentiality, our practice generally does not communicate with patients via text. However, email may be used in certain cases when clients are unable to upload necessary documents through a secure method.
For urgent or sensitive matters, please contact our office by phone to determine the most appropriate communication method.
LEGAL TESTIMONY
Legal matters requiring the testimony of a mental health professional can arise. This, however, can be damaging to the relationship between a patient and provider. As such, we recommend that you hire an independent forensic mental health professional for such services. We generally do not provide this type of legal testimony or support.
Fees for court appearances, whether by subpoena or client request, are $250 per hour. The fee includes travel and prep time that may be required for the appearance. Emails or phone calls with attorneys, even at the request of a client, will be charged at $150 per incident. In addition, there is a cost-based fee to process a request for records to be released to court, an attorney, or other individual. These fees are incurred on top of regular session fees. Doxa Health and Wellness LLC reserves the right to not respond to requests to appear in court or provide documents.
CHART CLOSURE
It is our practice policy that an active appointment must always exist in order to keep your chart open with us. It is of utmost importance to us to provide the best possible level of mental health care. This requires maintaining regular appointments. If an appointment is missed or cancelled by you, it is your responsibility to reschedule it as soon as possible. Our administrative staff may attempt to contact you to help make this as easy as possible for you. However, if you do not return our calls and/or emails, we cannot keep your chart open indefinitely and will need to close your chart. Please remember that you can always contact us to consider reopening your chart or if you need any alternative referrals.
Your signature below indicates that you have read the entire ‘Consent for psychiatric services / Practice Policies’ form – which contains information about our services, sessions, professional fees, billing & payments, cancellation & no-show policies, insurance reimbursement, contacting providers, professional records, confidentiality, email & texting policy, legal testimony, and chart closures – and you agree to abide by its terms during our professional relationship.
You acknowledge that a copy of the Doxa Health and Wellness LLC Patient Rights and Responsibilities, as well as a copy of the Notice of Privacy Practice have been made available to you.