Payment is expected at the time services are rendered unless prior payment arrangements have been approved by Modern Health LLC.

Patients choosing to self-pay are expected to pay in full at the time of service or have approved payment arrangements in place before receiving additional services.

I understand that I am responsible for any balance that becomes my responsibility after my insurance has processed my claim.

To provide efficient billing and reduce administrative delays, Modern Health LLC requires all patients to maintain a valid credit or debit card on file through our secure patient portal.

I understand that:

I will receive access to the Modern Health patient portal after I become an established patient.
I am responsible for logging into the patient portal and securely adding and maintaining a valid payment method before or shortly after my first appointment.
Modern Health LLC does not collect or store my credit card information through paper forms or online intake forms.
My payment information will be entered directly into the secure patient portal, which complies with applicable payment security standards.
It is my responsibility to keep my payment information current. If my card expires or changes, I agree to promptly update my information in the patient portal.
I authorize Modern Health LLC to charge the payment method I place on file in the secure patient portal for:

Copayments
Deductibles
Coinsurance
Self-pay balances
Outstanding patient balances
Charges that become my responsibility after insurance processing
Applicable late cancellation or no-show fees in accordance with Modern Health LLC's policies
This authorization will remain in effect until I revoke it in writing and provide an alternate acceptable payment method or until my account is closed.

We understand that unexpected delays happen; however, we must also respect the schedules of our other patients.

If you anticipate arriving late, please contact our office as soon as possible.
Patients arriving more than 10 minutes late may be asked to reschedule their appointment.
While we will make every effort to accommodate late arrivals, we cannot guarantee that you will be seen.

Appointments must be canceled or rescheduled at least 24 business hours before the scheduled appointment time.

Failure to provide adequate notice or failure to attend a scheduled appointment may result in a late cancellation or no-show fee in accordance with Modern Health LLC's current fee schedule.

Repeated missed appointments or late cancellations may result in dismissal from the practice.

By signing below, I acknowledge that:

• I have read and understand the Financial Responsibility Policy.
• I understand and agree to the Appointment Cancellation, No-Show, and Late Arrival Policies.
• I understand that Modern Health LLC requires a valid payment method to be maintained through the secure patient portal.
• I agree to log into the patient portal and securely add my payment information as instructed after becoming a patient.
• I authorize Modern Health LLC to charge the payment method I place on file in the patient portal for balances and fees described in this agreement.
• I understand that this authorization will remain in effect until revoked in writing and accepted by Modern Health LLC.

Modern Health LLC is updating how we communicate with our patients regarding upcoming appointments and other important information. 

You will receive an appointment reminder two (2) business days prior to your scheduled appointment. We also offer the option to receive appointment reminders and other communications via text message and email.

With your consent, Modern Health LLC may send you communications including, but not limited to:

Appointment reminders and confirmations
Appointment scheduling or rescheduling notifications
Prescription refill reminders
General health reminders (such as routine screenings or laboratory testing)
Billing or insurance-related notifications
Announcements regarding new services offered by our practice
Office closures, holiday hours, or weather-related delays
Other administrative communications related to your care
Modern Health LLC does not charge for this service; however, standard messaging and data rates may apply based on your mobile carrier or internet provider.Providing your consent is completely voluntary. If you choose not to receive text messages or emails, your care and services at Modern Health LLC will not be affected. You will continue to receive important communications by telephone when appropriate.

You may revoke or change your communication preferences at any time by notifying Modern Health LLC in writing.

If you have questions regarding the privacy of your health information, please contact our office at 

(815) 900-7330.

If you experience technical issues after enrolling in electronic communications, please contact our office at (815) 900-7330.

Risks of Electronic Communication

While Modern Health LLC makes every reasonable effort to protect your privacy, text messages and email are not always secure methods of communication.

Electronic communications may:

Be intercepted by unauthorized individuals.
Be forwarded, stored, or viewed by unintended recipients.
Remain on mobile devices or email servers.
Be accessed if your phone, tablet, or email account is compromised.

Text messages and emails may include limited information such as:

Your first name
Appointment date and time
Provider name
Clinic location
Office telephone number
General administrative information regarding your care
Modern Health LLC cannot guarantee the security or confidentiality of electronic communications but will use reasonable safeguards to protect your information.

Acknowledgment of Receipt of Notice of Privacy Practices
I acknowledge that I have been provided with or given the opportunity to review the Notice of Privacy Practices for Modern Health LLC, which explains how my medical information may be used and disclosed, and how I can access this information.

I understand that Modern Health LLC reserves the right to change its Notice of Privacy Practices at any time, and I may request a current copy at any time.

Consent for Use and Disclosure of Protected Health Information (PHI)
I hereby consent to the use and disclosure of my Protected Health Information (PHI) by Modern Health LLC for purposes including, but not limited to:
Treatment and coordination of care
Payment and billing activities
Healthcare operations (quality improvement, administrative functions, etc.)
I understand that my healthcare information may be shared with other healthcare providers, insurance companies, or third parties as necessary for my care and payment processing.

Patient Rights
I understand that I have the right to:
Request restrictions on how my information is used or disclosed
Request confidential communications
Inspect and obtain a copy of my medical records
Request amendments to my health information
Receive an accounting of disclosures of my PHI
Authorization to Release Information (Optional)
I authorize Modern Health LLC to release my medical information to the following individuals:

I understand the contents of this form. By signing below, I acknowledge receipt of the Notice of Privacy Practices and consent to the use and disclosure of my health information as described above.

Provider: Nicole Hendrickson, PMHNP

Consent for Treatment, I voluntarily consent to receive psychiatric and behavioral health services from Modern Health LLC and its providers.
I understand that treatment may include, but is not limited to:

Comprehensive psychiatric evaluation
Diagnostic assessment
Medication management
Ongoing psychiatric follow-up appointments
Review and interpretation of laboratory studies and diagnostic testing
Ordering laboratory tests or diagnostic imaging when medically appropriate
Coordination of care with my primary care provider, therapist, specialists, pharmacy, hospital, or other healthcare professionals involved in my care
Referrals to other healthcare providers or specialists when medically indicated
Education regarding my diagnosis, medications, treatment options, lifestyle modifications, and available resources
I understand that mental health treatment is individualized and that no guarantees or promises can be made regarding treatment outcomes.

Risks and Benefits
I understand that psychiatric treatment may provide significant benefits, including improvement in symptoms and overall functioning. However, I also understand there are risks associated with treatment, including but not limited to:

Medication side effects
Allergic reactions
Medication interactions
Incomplete symptom improvement
Worsening of symptoms despite treatment
The need for medication adjustments or additional treatment
My provider will discuss the risks, benefits, and alternatives of recommended treatments with me, and I will have the opportunity to ask questions before making treatment decisions.

Patient Responsibilities
I agree to:

Provide complete and accurate information regarding my medical and psychiatric history.
Inform my provider of all medications, supplements, allergies, and healthcare providers involved in my care.
Inform my provider if I become pregnant, plan to become pregnant, or begin breastfeeding.
Take medications only as prescribed.
Notify Modern Health LLC of any significant medication side effects or worsening symptoms.
Attend scheduled appointments or provide appropriate notice if I need to cancel or reschedule.
Follow office policies regarding medication refills and controlled substances.
Notify the office of changes to my address, telephone number, insurance, or pharmacy.
Medication Management
If medication is recommended, I understand that:
Medication recommendations are based on clinical judgment and current standards of care.
I have the right to ask questions regarding any recommended medication.
I may accept or decline medication after discussing the risks and benefits with my provider.
Regular follow-up appointments may be required before medications can be continued or refilled.
Certain medications may require laboratory monitoring or additional testing.
Confidentiality
My medical information will be maintained in accordance with applicable federal and state privacy laws, including HIPAA.
I understand there are exceptions to confidentiality when disclosure is required or permitted by law, including but not limited to:

Imminent risk of harm to myself or another person
Suspected abuse or neglect of a child, elderly person, or vulnerable adult
Court orders or other legal requirements
Medical emergencies
Other situations required by federal or state law
Emergencies
I understand that Modern Health LLC is an outpatient practice and does not provide emergency or crisis services.
If I experience a medical or psychiatric emergency, I agree to:

Call 911
Go to the nearest emergency department
Contact the 988 Suicide & Crisis Lifeline by calling or texting 988

I understand that messages left after business hours may not be reviewed until the next business day.

 

Telehealth Services
If I participate in telehealth appointments, I understand that:
Telehealth uses secure electronic communication technology.
Technical interruptions may occasionally occur.
I may request an in-person appointment when clinically appropriate.
I may withdraw my consent for telehealth services at any time.
Consent to Coordinate Care
I authorize Modern Health LLC to communicate with my pharmacy, laboratory, therapist, primary care provider, specialists, hospital, and other healthcare providers involved in my treatment when necessary for treatment, payment, or healthcare operations, as permitted by law.

Acknowledgment
By signing below, I acknowledge that:

I have read and understand this Consent for Psychiatric Evaluation and Treatment.
I have had the opportunity to ask questions, and my questions have been answered to my satisfaction.
I understand the nature, risks, benefits, and alternatives of treatment.
I voluntarily consent to receive psychiatric evaluation and treatment from Modern Health LLC.
I understand that I may withdraw my consent for treatment at any time; however, doing so may limit the provider's ability to continue my care.

Parent or Legal Guardian (Required for Patients Under 18 Years of Age)

I certify that I am the parent or legal guardian of the above-named patient and have the legal authority to consent to psychiatric evaluation and treatment on the patient's behalf.

 

Provider: Nicole Hendrickson, PMHNP

Purpose
Controlled substances can be highly effective when used appropriately; however, they also carry risks, including misuse, abuse, dependence, diversion, and overdose. This agreement outlines the responsibilities of both the patient and Modern Health LLC to promote safe and effective treatment.

By signing this agreement, I understand and agree to the following:

Designated Pharmacy
I agree to use only the pharmacy listed below for all prescriptions of controlled substances prescribed by Modern Health LLC unless I receive prior approval from my provider.

I understand that changing pharmacies without notifying Modern Health LLC may delay or prevent refills.

Prescribing Provider

I agree that Nicole Hendrickson, PMHNP, or another authorized provider at Modern Health LLC, will be my primary prescriber for controlled substances prescribed by this practice.

I agree not to obtain prescriptions for the same or similar controlled substances from another healthcare provider without notifying and receiving approval from my provider at Modern Health LLC, except in a true medical emergency or when another provider has been specifically authorized to prescribe.

If I receive a controlled substance from another provider (including an emergency room, urgent care, dentist, surgeon, or specialist), I agree to notify Modern Health LLC as soon as possible.

 

Medication Responsibilities

I agree to:

Take my medication exactly as prescribed.
Never take more medication than prescribed.
Never share, sell, trade, or give my medication to another person.
Store my medication in a safe and secure location.
Protect my medication from loss or theft.
Never alter or misuse my medication.
Use my medication only for the medical condition for which it was prescribed.
Refills
I understand and agree that:
Controlled substance refills are provided only during normal business hours.
Refill requests should be submitted at least 72 business hours before the medication is needed.
Early refill requests are generally not approved.
Lost, stolen, damaged, or misplaced medications may not be replaced.
Repeated requests for early refills may result in modification or discontinuation of treatment and may result in dismissal from the practice.
Prescription Monitoring
I understand that Modern Health LLC participates in and reviews the applicable Prescription Drug Monitoring Program (PDMP) before prescribing controlled substances.
I authorize my provider to review my prescription history and coordinate care with other healthcare providers, pharmacies, or insurance companies as permitted by law.

Drug Screening
I understand that my provider may request random urine drug screening or other laboratory testing as part of my treatment.
Failure to comply with requested testing may result in discontinuation of controlled substance prescribing.

Pill Counts
If requested, I agree to present my medication for a pill count within the timeframe requested by Modern Health LLC.
Failure to comply may result in discontinuation of controlled substance prescribing.

Reasons Controlled Substance Therapy May Be Discontinued

I understand that Modern Health LLC may discontinue prescribing controlled substances or terminate the patient-provider relationship if any of the following occur:

 

 

Obtaining controlled substances from another provider without notifying Modern Health LLC.
Using more medication than prescribed.
Selling, sharing, diverting, or altering medication.
Repeated requests for early refills.
Repeatedly reporting medications as lost or stolen.
Evidence of medication misuse, abuse, diversion, or fraud.
Failure to comply with urine drug screens or pill counts.
Providing false or misleading information regarding medication use.
Threatening or abusive behavior toward staff.
Violation of this agreement or other office policies.
Discontinuation of controlled substance prescribing does not necessarily mean dismissal from the practice; however, serious or repeated violations may result in termination from Modern Health LLC in accordance with applicable laws and practice policies.

I acknowledge that I have read and understand this Controlled Substance Treatment Agreement. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand the responsibilities outlined in this agreement and agree to comply with all terms and conditions.

If the patient is a minor, I certify that I am the patient's parent or legal guardian and have the legal authority to consent to treatment and to this agreement on the patient's behalf. I understand that I am responsible for ensuring the medication is administered as prescribed, stored securely, and safeguarded from misuse, diversion, theft, or accidental ingestion.

with the individual or organization listed below for the purpose(s) identified in this authorization

Patient Rights
I understand that:

I may revoke this authorization at any time by providing written notice to Modern Health LLC, except to the extent action has already been taken in reliance on this authorization.
Refusing to sign this authorization will not affect my ability to receive treatment or services.
Information released under this authorization may no longer be protected by HIPAA if redisclosed by the recipient.
I have the right to receive a copy of this signed authorization.

Authorization
I have read this authorization and understand its contents. I voluntarily authorize Modern Health LLC to release, obtain, or exchange my protected health information as described abo

Parent or Legal Guardian (Required if Patient is a Minor or Legally Represented)

I certify that I am the patient's parent or legal guardian, or otherwise have legal authority to authorize the release of the patient's protected health information.

Thank you for choosing Modern Health for your mental health care. We appreciate you taking the time to complete your new patient intake forms and assessment.

Your completed forms will be reviewed by our clinical team prior to your appointment to help ensure we provide you with the highest quality care from your very first visit.

If you have any questions regarding your upcoming appointment, your assessment, your new patient forms, or your insurance information, please don't hesitate to contact our office. Our team is happy to assist you.

Phone: 815-900-7330
Email: Alexzandra@mymodernhealth.org , MaggieMcBride@mymodernhealth.org 

We look forward to partnering with you on your mental health journey and are honored to be a part of your care.

Thank you again for choosing Modern Health.