Elevated Image & Primary Care

Introduction

 

Welcome to Elevated Image & Primary Care. We are committed to providing quality medical aesthetics and primary care services. This document explains your rights, responsibilities, and consent to treatment.

 

NATURE OF SERVICES

Services may involve discussions of personal challenges and goals. Specific treatments may be recommended based on your individual needs.

There are potential benefits (e.g., symptom relief, improved functioning) and risks (e.g., emotional discomfort, side effects from medication).

CONFIDENTIALITY 

All information you share is confidential except in the following circumstances:

If you pose a risk to yourself or others.
If there is suspicion of abuse or neglect of a child or vulnerable adult.
If required by a court order.

TELEHEALTH SERVICES

If sessions are conducted online, all efforts will be made to ensure your privacy. However, there are risks with technology that cannot be entirely eliminated.

 

MEDICATION MANAGEMENT

If prescribed medication, you will be informed about its intended use, potential side effects, and alternative options.

FEES AND BILLING 

Information about session costs, payment policies, and insurance (if applicable).

CONSENT TO TREATMENT

By signing below, you confirm that:

You have had an opportunity to ask questions.
You understand the benefits and risks of treatment.
You consent to receive services and care from Elevated Image & Primary Care.

INFORMED CONSENT

I understand that the information obtained in this evaluation is confidential and will not be released to any person or organization without my written permission. (This release is available in our office or may be completed with any individual whom you wish to give such access, and then provided to us.) The only exceptions to this policy are rare situations in which you are required by law to release information with or without my permission.

These are: 1) if there is evidence of physical and/or sexual abuse of children or abuse to the elderly; 2) if you judge that I am in danger of harming myself or another individual; and 3) if my records are subpoenaed by the court. In the rare event of any of these situations, you would attempt to discuss your intentions with me before an action is taken, and you would limit disclosure of confidential information to the minimum necessary to ensure safety.

CONSENT

I voluntarily give my consent to participate in this study. I have read the information above or the said information was read to me. I was given the opportunity to ask questions and these were answered satisfactorily and to my contentment. 

CLINIC POLICIES

APPOINTMENT POLICIES
Initial evaluations, assessments, and full sessions are about 30 to 60 minutes long. Subsequent follow-up sessions range from 15 to 30 minutes in duration, and medication management sessions
are about 15 minutes. However, these durations can vary depending on the case and may require more time than expected.
All paperwork and co-pay submissions are rendered before the beginning of the session. Please arrive 15 minutes before your scheduled appointment for ease of operations. Please respect time guidelines so that the next patient waiting is not affected. If you return after one year, you will be considered a new patient and must be re-evaluated.

URGENT/EMERGENCY SERVICES
We are an outpatient clinic and are not equipped to handle emergency medical services. We want to ensure you are given proper care. For this reason, we recommend that if you experience any critical adverse reaction or present current suicidal ideation, please get in touch with 911 or visit the nearest emergency room. After you have received urgent care, please follow up with your outpatient provider to discuss any changes made at the hospital (the hospital will also recommend this before discharge).

24-HOUR CANCELLATION POLICY & LATE ARRIVALS

Cancellation & late arrival phone number: 206

LATE ARRIVALS:
If you arrive late, the provider may see you on that day or request a reschedule for a future date. Please know that calling in to notify of late arrival does not guarantee you will be seen, as we do not have a grace period.

ABOUT THE 24-HOUR CANCELLATION POLICY:
Please call the clinic for all appointment cancellations or changes 48 hours before your scheduled appointment, or you may accrue a no-show fee.
Reason for this policy: Notifying the clinic 48 hours in advance of your intention to cancel or reschedule gives an opportunity to schedule someone else for that time slot. This window period is essential because others may be on a waiting list looking for a chance to reschedule for a different time.

**If you do not show up for a scheduled appointment, please know that you will be charged for the missed appointment.

**An email or voicemail notification given within the time frame is acceptable as proper notification.
Because it is illegal to bill your insurance company for a missed appointment, you will pay for the full fee of the missed session out-of-pocket (resulting in a much higher payment than you may have paid for a kept appointment). The hourly cash rate will vary per/hour per provider.

Please note that this cancellation policy is standard in medical and mental health practices and will be strictly enforced. On occasion, there will be understandable reasons for missing appointments, but exceptions to this policy will be rare. If you have three (3) no-shows within a calendar year, we will discontinue treatment services.

 

REFILL POLICIES

• Please notify the office at the time of your appointment if you are running out of medication so that we can avoid medication shortages.

• If you have a mail-in series, please mail the forms and prescriptions after we fill them out to avoid any confusion.

• Medication refills must be taken care of during your appointment. If you run out of medicines in unforeseen circumstances, please contact the clinic during regular business hours. We will be happy to refill your non-controlled medications if you have a scheduled follow-up appointment or will schedule you with the next available provider.

• Controlled lost/stolen prescriptions may require a police report and will only be refilled if clinically safe.

• Refills do not guarantee mediation coverage; please get in touch with your pharmacy regarding coverage.

 

FORMS OF COMMUNICATION
• You may contact our clinic via phone, email, online form submissions, Yelp messaging, or voicemail.

• Please allow our front staff up to two business days to reply to your emails.

• Providers may have their own turnaround time for email response; please discuss this with your provider.

• Voicemails are returned within one business day. Please make sure to leave a complete message so that we can adequately assist you.

• The clinic will send text and email reminders to the number and/or email address you provided. These reminders are complementary, please make sure to also keep note of your appointment. Please advise our staff if you want to remove these reminders at any time.

 

FORMS/PAPERWORK

Please discuss any requested forms. However, it is up to the provider’s discretion to agree to forms, letters, and disability paperwork. Our general turnaround time on paperwork is 5 to 7 business days (up to 14 business days in some forms) but can vary in unforeseen circumstances.

Please make sure to bring in your requests promptly. All requested documents and forms requiring provider completion are subject to billing fees. Insurance does not cover billing fees and you have to pay for them out-of-pocket.

 

MEDICATION PRIOR AUTHORIZATION
Our clinic may submit PAs for medications. Please get in touch with the clinic so we have your most updated insurance, contact, and billing information. However, please know that prior authorization approvals are not guaranteed and are dependent on your insurance. Prior authorizations may take 5 to 7 business days to complete from the day we are notified of the request.

SWITCHING PROVIDERS
Please note that you can see another provider within our clinic if your provider is unavailable. This practice is not considered switching providers. Switching providers means you would like to stop the care with your current provider and start your care with another. Our goal is for you to have an established relationship and continued care. We will limit switching providers to 2 times. When
switching providers, it must be for a reason other than not agreeing to a treatment plan (such as requesting particular medications that a provider declined, requesting increased dosages that a provider declined, requesting controlled medications that a provider declined, etc.). Medications and treatment plans are based on your provider’s evaluation and are only given when medically appropriate. If you disagree with your treatment plan, you may seek a second opinion outside our clinic.

PATIENT TERMINATION
Our mission is to provide quality care for all of our existing patients. The collaborative relationship between our office and our patients is essential to the care received, and any damage to said collaboration may be detrimental. Please see below for possible reasons for discharge.
• Noncompliant to treatment
• Failure to adhere to attendance policy
• Failure to adhere to clinic policies
• Aggressive or violent behavior

 

FINANCIAL TERMS
Please obtain prior authorization for treatment from your insurance company. You are also responsible for all co-pays and insurance services when rendered and for charges not covered by your insurance.

If you become aware at any time during your treatment that you are ineligible for insurance coverage, please notify the clinic immediately because you will be financially responsible for 100% of the billed charges for ineligible health services.

Please notify the clinic of charges to your personal and insurance information.
For Medicare Patients, please pay 20% of the initial visit, all follow-up visits, and any deducible amount.

PAYMENT TERMS AND UNCOVERED SERVICES
For services required outside the treatment session, please know that you will be charged the regular hourly rate of $150-$275. These services include consultations with other professionals.

You will also be charged a fee for conservatorship, petitions, disability forms, or any letter required for medical leave.

Please note that you will pay any or all expenses incurred, including reasonable attorney fees if the clinic must employ an attorney to enforce any of these conditions.

Type of Payment: Services are payable in advance of each appointment. Please make checks payable to the clinic or pay by cash or credit card. Receipts will only be given upon request at the beginning of your appointment.

Prompt Payment: Balances not paid within 30 days are considered “PAST DUE.” Balances not paid within 60 days may be sent to our collections agency or pursued by a small claims court. If you cannot fully pay, please set up a payment arrangement plan with our billing department (the amount may vary).

Insurance Claims: Please note that you are required to pay for all services rendered that are not covered by your insurance carrier.

RETURN CHECK FEE: The returned check fee is $25.00. If a check is returned without having been paid for any reason, the patient will pay an additional fifty dollars ($50.00) as a non-sufficient fund payment.

RIGHT TO END THERAPY: Please note that you have the right to end therapy at any time with no obligation except to pay for completed services.