BLUE RIDGE BEHAVIORAL HEALTH
170 Thomas Johnson Drive, Suite 200, Frederick, MD 21702
Phone: 301-695-8390 / Facsimile:301-694-7906

PATIENT RIGHTS AND RESPONSIBILITIES

Patients have the right:

1. To be treated humanely, with dignity, and respect.
2. To not be discriminated against due to race, religion, ethnicity, gender, sexual orientation or disability.
3. To receive treatment appropriate to their mental health condition.
4. To have diagnosis and treatment explained in understandable terms.
5. To participate in the formulation and revision of the treatment plan.
6. To refuse treatment, request another provider or seek a referral outside of the practice.
7. To receive services that adhere to the principles of confidentiality and privacy. Audio and/or video recording of any appointment or phone consultation is strictly prohibited. Exceptions to patient confidentiality apply for the following specialized circumstances:
   1. When circumstances place the patient’s welfare or that of others in immediate danger.
   2. When disclosures made by the patient raises the suspicion of child physical, mental, or sexual abuse or neglect or if an adult discloses an allegation of abuse in their childhood. In this situation, the law requires a report to be made to the appropriate agency, usually Social Services.
   3. When a court order requires testimony or release of patient’s records.
   4. In a circumstance where the provider determines that consultation within the practice is needed in order to provide optimal treatment, in which case the utmost discretion will be used to ensure privacy.
8. To access your medical record as deemed appropriate by the provider.

Patients have the responsibility:

1. To know the benefits and exclusions of your insurance coverage and to provide us with current insurance information.
2. To make regular and prompt payments for services rendered. Payment in full for any outstanding balance is required prior to being scheduled or seen for any future services, including referrals for additional services with other providers at Blue Ridge Behavioral Health, unless prior arrangements have been made with the Office Manager or your clinician.
3. To keep scheduled appointments. Patients will be charged missed appointment fees for missed, cancelled or rescheduled appointments for which 24 business hours’ notice has not been given. Missed appointment fees will also be charged if patients are not located in Maryland or experience issues with their internet service, equipment or technology that prevents patients from completing their scheduled telehealth appointments.
4. To follow the mutually agreed upon treatment plan.
5. To be open and honest in sessions.
6. To report any safety concerns or abuse allegations to your provider.
7. To treat all Blue Ridge Behavioral staff and clinicians with courtesy and respect.
8. To discuss with your provider any concerns about treatment, including the desire to terminate treatment.

By signing below, I acknowledge and agree to the rights and responsibilities as outlined above.