FUSE MENTAL HEALTH
1050 Queen Street, Suite 200
Honolulu, HI 96814
(650) 275-2585
support@fusementalhealth.com

Effective Date: April 1, 2026

NOTICE OF PRIVACY PRACTICES, INFORMED CONSENT, AND PRACTICE POLICIES

Aloha and welcome to Fuse Mental Health! Please review this document as it describes how your health information may be used and disclosed, outlines your rights, and establishes the terms and conditions governing services provided by Fuse Mental Health. Services may include psychotherapy, psychiatric evaluation, medication management, controlled substance prescribing, ketamine-assisted treatment, integrative services, and telehealth.

By signing this document, you acknowledge receipt of this Notice of Privacy Practices, Informed Consent and Practice Policies and provide informed consent for services under the terms described herein.

PRACTICE POLICIES AND PROFESSIONAL TERMS

Appointments require at least 24 hours notice for cancellation or rescheduling. Late cancellations or missed appointments will be charged in full.

Fuse Mental Health is not an emergency service. In emergencies, you must call 911 or go to the nearest emergency department. Communication outside of sessions is limited. Electronic communication is not secure and should be used only for administrative purposes. Fuse Mental Health does not engage with clients on social media. Services may be terminated when clinically appropriate, for nonpayment, or due to nonattendance, with reasonable efforts made to avoid abandonment.

INFORMED CONSENT FOR CLINICAL SERVICES

You are voluntarily seeking services from Fuse Mental Health. Services may include, but are not limited to, psychotherapy, psychiatric evaluation, diagnosis, medication management, controlled substance prescribing, ketamine-assisted treatment, and integrative or adjunctive interventions. The specific services provided will be determined based on clinical evaluation and ongoing treatment planning.

The purpose of treatment is to assess, diagnose, and address mental health conditions and related concerns. This may involve discussion of personal history, emotional experiences, behaviors, relationships, and other sensitive topics. Treatment may include therapeutic interventions, medication, or other modalities deemed clinically appropriate.

Potential Benefits
Potential benefits of treatment may include reduction in symptoms, improved emotional regulation, enhanced insight, improved functioning, and overall improvement in quality of life. Benefits are not guaranteed and vary based on individual factors including participation, diagnosis, and external circumstances.

Material Risks and Discomforts
Participation in treatment may involve risks. These include emotional discomfort, increased awareness of distressing thoughts or feelings, temporary worsening of symptoms, and interpersonal or life changes resulting from increased insight or behavioral change. Psychiatric treatment, including medication management, may involve side effects, medication interactions, allergic reactions, or other medical risks. Certain interventions, including ketamine-assisted treatment, involve additional risks as described elsewhere in this document.

There is a risk that treatment may not be effective, and in some cases symptoms may persist or worsen despite appropriate care.

Alternatives to Treatment
Alternatives to services at Fuse Mental Health include, but are not limited to, receiving care from another provider, pursuing different therapeutic modalities, medication-only treatment, non-medical or community-based support, or choosing no treatment. You have the right to discuss these alternatives and to seek a second opinion.

No Treatment Option
You have the right to decline treatment. You understand that declining or discontinuing treatment may result in persistence or worsening of symptoms and other consequences depending on your condition.

Nature of the Therapeutic and Clinical Relationship
The clinical relationship is professional in nature and is not a personal, social, or reciprocal relationship. Boundaries are maintained to support safe and effective care. Services are based on clinical judgment and professional standards, and providers may make recommendations regarding treatment that you may accept or decline.

Confidentiality and Its Limits
Information shared in treatment is confidential except where disclosure is required or permitted by law. These exceptions include, but are not limited to, situations involving risk of harm to yourself or others, suspected abuse or neglect of a child, elder, or dependent adult, court orders or legal proceedings, and certain health oversight or law enforcement requirements.

You understand that electronic communications may not be fully secure and that telehealth services carry additional confidentiality risks.

Patient Responsibilities
You agree to provide accurate and complete information regarding your medical history, psychiatric history, medications, substance use, and current symptoms. You agree to follow treatment recommendations to the extent you choose to participate, including medication instructions and safety guidelines.

You agree to inform your provider of any changes in your condition, side effects, or concerns related to treatment. Failure to provide accurate information may impact the safety and effectiveness of care.

Voluntary Participation and Right to Withdraw
Your participation in treatment is voluntary. You may refuse or discontinue any treatment at any time, except where treatment is mandated by law. You understand that discontinuing treatment may have clinical consequences, and these will be discussed with you when applicable.

Capacity and Opportunity for Questions
By signing this document, you acknowledge that you have the capacity to consent to treatment or are legally authorized to do so. You confirm that you have had the opportunity to ask questions about the nature of treatment, risks, benefits, and alternatives, and that your questions have been answered to your satisfaction.

No Guarantee of Outcome
You understand that Fuse Mental Health makes no guarantees regarding the outcome of treatment. Clinical decisions are made based on professional judgment and available information, and results may vary.

Documentation of Consent
Your signature indicates that you have read and understood this section, that you have had the opportunity to ask questions, and that you voluntarily consent to receive services under the terms described.

TELEHEALTH INFORMED CONSENT

Telehealth services involve electronic communication technologies and may differ from in-person care. Services will be provided only when clinically appropriate and based on an evaluation sufficient to establish diagnosis and assess limitations of telehealth care. Risks include technical failure and potential confidentiality limitations. You may withdraw consent at any time. Telehealth is not appropriate for emergencies.

KETAMINE-ASSISTED TREATMENT INFORMED CONSENT

Ketamine-assisted treatment may be provided as part of your care and may be considered off-label. Potential benefits include symptom relief and improved therapeutic engagement. Outcomes are not guaranteed. Risks include dissociation, perceptual changes, anxiety, nausea, cardiovascular effects, sedation, and rare adverse events. You agree not to drive or engage in hazardous activities for at least 24 hours following treatment.

Risk Disclosure

Ketamine and similar treatments may produce significant alterations in perception, cognition, and emotional processing. Risks include psychological distress, resurfacing trauma, temporary worsening of symptoms, and unpredictable emotional responses. Medical risks include cardiovascular effects, sedation, dizziness, nausea, and rare complications. Repeated use may carry risks including cognitive changes, urinary symptoms, and potential misuse. Ketamine is not recommended during pregnancy due to limited human safety data, potential fetal neurotoxicity, and animal studies suggesting harm to developing brains. You acknowledge that alternative treatments exist and that participation is voluntary.

Post-treatment Safety, Liability, and Transportation Acknowledgment

You agree not to drive or engage in unsafe activities following treatment until medically cleared. You agree to arrange safe transportation and, when required, accompaniment by a responsible adult. You assume responsibility for following all safety instructions. Fuse Mental Health is not responsible for harm resulting from failure to follow these instructions.

CONTROLLED SUBSTANCE AGREEMENT

Controlled substances will be prescribed only in accordance with federal and Hawaiʻi law and only after a bona fide practitioner-patient relationship has been established. You agree to take medications as prescribed and not to obtain controlled substances from other providers without disclosure. You agree to use a single pharmacy unless otherwise approved. Monitoring may include prescription monitoring program review and other clinically appropriate measures. Misuse, diversion, or noncompliance may result in discontinuation of prescribing.

GOOD FAITH ESTIMATE AND NO SURPRISES ACT NOTICE

You have the right to receive a Good Faith Estimate of expected charges if you are uninsured or choose not to use insurance. Fuse Mental Health will provide Good Faith Estimates in accordance with federal law upon scheduling or request. If you receive a bill that is at least $400 more than your estimate, you have the right to dispute the charge. Additional items or services may be recommended as part of your care and may need to be scheduled or requested separately; those services are not included in this Good Faith Estimate. This Good Faith Estimate is only an estimate of the items, services, and charges reasonably expected at this time. Actual services or charges may differ. You may have the right to start a patient-provider dispute resolution process if your actual billed charges are substantially higher than this estimate. More information is available at www.cms.gov/nosurprises. Starting a dispute will not affect the quality of care you receive. This Good Faith Estimate is not a contract and does not require you to receive services from any provider or facility listed.

For transparency, if you do not have insurace covering the medical costs associated with your care, then you will have to self-pay expenses (i.e., out of pocket payment). In this case, you can expect to pay according to table provided below. Please note that your first session will always be the the psychiatric diagnostic and subsequent appointments are considered to be follow-up sessions as indicated in the table below:

CPT Code	Description	Base Fee	GET + Payment Processing Fees	Estimated Total
90792	First Session - Psychiatric Diagnostic	$360	$30.15	$390.15
99213	Follow-Up - Psychiatry Appointment	$180	$15.24	$195.24
90837	Follow-Up - Psychotherapy Appointment	$180	$15.24	$195.24

Your first session, the psychiatric diagnostic intake, will be provided by Dr. William Portman, MD, with individual NPI 1639551294, under the entity Fuse Mental Health, with organizational NPI 1306784095 and EIN 415059217.

FINANCIAL POLICY AND PAYMENT TERMS

You are responsible for all charges, including missed appointments. Insurance coverage is not guaranteed. You are responsible for denied or non-covered services.

You authorize Fuse Mental Health to charge your payment method on file for services rendered and applicable fees. You agree to notify the practice of any billing concerns so they may be reviewed. Outstanding balances may result in suspension of services and may be referred to collections.

You understand and acknowledge that fees for services provided by Fuse Mental Health may be subject to applicable Hawaiʻi state and county taxes, including Hawaiʻi General Excise Tax (“GET”), as well as secure electronic payment processing fees associated with credit card or electronic transactions. Current Hawaiʻi GET rates applicable to services are presently 4.0% for State of Hawaiʻi tax and an additional 0.5% County of Honolulu surcharge, for a combined estimated tax rate of 4.5%, where applicable. In addition, payments processed electronically through Stripe via the SimplePractice platform are currently subject to payment processing fees consisting of $0.30 per transaction plus approximately 3.15% of the transaction amount.

By signing this document, you acknowledge and agree that these taxes and payment processing fees may be added to the cost of services and charged to your payment method on file in addition to professional service fees. You understand that tax rates, payment processing rates, and third-party platform fees are determined by governmental authorities and/or payment processors and may change in the future without prior notice. Fuse Mental Health reserves the right to update applicable charges, taxes, and processing fees as required or permitted by law and contractual obligations with third-party vendors. If you choose to use an alternative approved payment method that does not incur electronic processing fees, certain processing-related charges may not apply. You acknowledge that you have had the opportunity to ask questions regarding fees, taxes, and billing practices prior to consenting to services.

PAYMENT AUTHORIZATION AND AUTOMATIC PAYMENT CONSENT

By signing this document, you authorize Fuse Mental Health to charge your designated credit or debit card through Stripe via SimplePractice for services rendered, including but not limited to scheduled appointments, late cancellations, missed appointments, and any outstanding balances in accordance with the policies outlined in this agreement. Charges will appear on your bank or credit card statement.

You consent to the use of automatic payment processing (“autopay”) for all applicable charges. You authorize Fuse Mental Health to securely store your payment information and to charge your card on file for amounts owed without additional notice at the time of each transaction, including charges incurred after services are rendered or in accordance with cancellation policies. This authorization will remain in effect unless and until you revoke it in writing. You agree to provide updated payment information promptly if your payment method changes, expires, or is no longer valid. Fuse Mental Health may suspend services if a valid payment method is not maintained.

You acknowledge that you are the authorized user of the payment method provided or have legal authorization from the cardholder to use the payment method for these purposes. You agree to promptly notify Fuse Mental Health of any questions or concerns regarding charges so that they may be reviewed and addressed prior to initiating a dispute with your financial institution. You understand that payment transactions may include information that could be associated with protected health information, and you accept this risk as part of electronic payment processing. You have the right to request a paper copy of this authorization.

PRIVACY PRACTICES AND USE OF PROTECTED HEALTH INFORMATION

Fuse Mental Health maintains protected health information in accordance with HIPAA, HITECH, and applicable federal and Hawaiʻi laws. Protected health information may be used and disclosed for treatment, payment, and healthcare operations. For treatment purposes, disclosures are not limited to the minimum necessary standard. Protected health information may also be disclosed as required by law, including for public health, abuse reporting, health oversight, judicial or administrative proceedings, and to avert serious threats to health or safety. Psychotherapy notes will not be disclosed without your written authorization except as permitted by law. Fuse Mental Health does not sell protected health information and does not use it for marketing purposes. You will be notified of any breach of unsecured protected health information as required by law.

Fuse Mental Health will not use or disclose protected health information for purposes prohibited by federal law, including uses related to investigating or imposing liability for lawful reproductive health care. In certain circumstances, requests for information may require a written attestation confirming that the requested use or disclosure is not for a prohibited purpose. Information disclosed pursuant to HIPAA may be subject to redisclosure by the recipient and may no longer be protected under federal privacy law.

COMMUNICATION CONSENT (PHONE, TEXT, EMAIL, AND VOICEMAIL)

Fuse Mental Health may communicate with you for purposes including, but not limited to, appointment reminders, scheduling, billing matters, care coordination, and other administrative or clinical communications.

By signing this document, you consent to being contacted by Fuse Mental Health at the telephone number(s) and email address(es) you provide, including via phone call, voicemail, text message (SMS), and email.

You authorize Fuse Mental Health to leave voicemail messages at the phone number(s) you provide, including messages that may identify the practice and the nature of the communication, such as appointment reminders, unless you request otherwise. You understand that text messaging and standard email are not secure methods of communication and may involve some risk to the confidentiality of your information. You agree to accept these risks if you choose to communicate via these methods.

You agree not to use text messaging or email for urgent or emergency matters. Fuse Mental Health does not guarantee immediate response to electronic communications. In the event of an emergency, you agree to call 911 or go to the nearest emergency department. You understand that message and data rates may apply depending on your mobile carrier and plan. You may request limitations or opt out of certain forms of communication at any time by notifying Fuse Mental Health in writing. Fuse Mental Health will make reasonable efforts to accommodate your preferences; however, certain communications may still be necessary for treatment, payment, or healthcare operations.

YOUR RIGHTS REGARDING PROTECTED HEALTH INFORMATION

You have the right to request restrictions, confidential communications, access to records, amendments, and an accounting of disclosures. You have the right to file a complaint without retaliation. Complaints or questions regarding privacy practices may be directed to:

Dr. William Portman, MD
Privacy Officer, Fuse Mental Health
(650) 275-2585
support@fusementalhealth.com

You may also file a complaint with the U.S. Department of Health and Human Services. Fuse Mental Health will not retaliate against you for filing a complaint. Fuse Mental Health reserves the right to revise this Notice. Revised notices will apply to all protected health information maintained and will be made available upon request and on the practice website.

INFORMED CONSENT AND PATIENT RIGHTS

You have the right to make informed decisions regarding your care, including understanding the nature of proposed treatments, risks, benefits, alternatives, and the option to refuse or withdraw consent. You have the right to participate in treatment decisions and to be treated with dignity and respect. A signed copy of this consent will be maintained in your clinical record, and a copy will be made available to you upon request. You may refuse or withdraw consent to nonemergency treatment at any time. If consent is withdrawn, Fuse Mental Health will discuss appropriate alternatives and potential consequences of discontinuing treatment.

ACKNOWLEDGMENT OF RECEIPT AND INFORMED CONSENT

You acknowledge that you have been informed of the nature and purpose of the services offered, including potential risks, benefits, and available alternatives, including the option of no treatment. You acknowledge that you understand your rights and responsibilities, including your privacy rights under applicable law. You acknowledge that you have had the opportunity to ask questions regarding the information contained in this document and that all questions have been answered to your satisfaction. You voluntarily consent to receive services from Fuse Mental Health, including, where applicable, psychotherapy, psychiatric services, medication management, telehealth services, controlled substance management, and ketamine-assisted treatment. You understand that you may refuse or withdraw consent to treatment at any time, except where otherwise provided by law. You acknowledge that you have received the Good Faith Estimate and are aware of the estimated payment expense of your treatment.

By signing below, you acknowledge that you have received and reviewed this document titled “Notice of Privacy Practices, Informed Consent, and Practice Policies.” Mahalo for your patience and time taken to review this document!