Welcome to Middle Path Psychiatry, the office of Dr. Joshua A. Evans, MD. Please take a moment to read through the following, as we may not have the chance to review all the information together in person.

In this packet you will find sections regarding:

1. Contract and Consent for Evaluation/Treatment
2. Notice of Privacy Practices
3. Acknowledgment of Receipt of Notice of Privacy Practices
4. Authorization to Release Protected Health Information

NOTE: this is the Practice Introduction packet for patients who have a health insurance provider that is contracted with Middle Path Psychiatry for “In-Network” coverage. If you do not have a contracted insurance provider, please see the version of this packet that is intended for “Self-Pay” patients – which includes patients who are planning to file claims for “Out-of-Network” insurance benefits. If you are unsure or have questions about this, please contact Dr. Evans at Middle Path Psychiatry for clarification.

Middle Path Psychiatry
Joshua A. Evans, MD
950 S. Cherry St.
Suite 420
Denver, CO 80246
Phone: (720) 502-5670
Fax: (720) 502-5679

 

In consideration for receiving assessment, treatment and/or medication/psychiatric services, I/we agree to the following:

Fee Payment:

Middle Path Psychiatry provides services on a fee-for-service basis. The patient is responsible for full payment at the time of service. Fee schedules are determined by insurance provider contracts with Middle Path Psychiatry.

The patient will receive a monthly invoice/billing statement. Please be aware that diagnosis codes are included on these statements. For your privacy, please specifically request if you would not like diagnostic codes included on these statements.

Payment of the portion of the balance that is Patient Responsibility is due within 2 weeks of the date of the billing statement. If payment is not received by the 2 week due date, a $20 late fee will be assessed. If payment is not received, the account may be turned over to a collection agency within 30 days. Middle Path Psychiatry has the option to pursue all lawful collection procedures available, and the patient will be responsible for all costs of collection, including attorney fees. Failure to pay may result in termination of services.

Unless otherwise agreed upon, credit card will be the primary form of payment for professional services. A valid credit card must be on file at all times. At this time, Visa, MasterCard, and Discover are accepted. The patient authorizes Middle Path Psychiatry to charge their credit card for any payments due at the time of service. If any Patient Responsibility payment is more than 2 weeks overdue from the date of the billing statement, the patient authorizes Middle Path Psychiatry to charge their credit card for the overdue balance. Credit card payment is processed through Complete Merchant Services, a secure online credit card payment processing service used by Middle Path Psychiatry. The patient will not be assessed any additional processing fees for this service. Credit card information is not physically kept on file in this office, rather it is securely stored electronically.

The patient may also use cash or check for payment. Patients will be assessed a fee of $50 for each returned check.

Insurance:

It is the patient’s responsibility to know their insurance policy coverage details, including but not limited to contracted fee schedule, payments due at time of service, deductible, and other details of the patient’s financial responsibility for professional services provided by Middle Path Psychiatry.

It is the patient’s responsibility to notify Middle Path Psychiatry with any insurance changes and to obtain any required authorizations. Our office will submit claims to the insurance company we have on file. Per our contractual agreement with insurance companies we must collect all co-payments and/or deductibles due from the patient. Co-payment and/or deductibles are due at the time of service. Should the insurance company not cover the cost of the provided service, payment of the balance will become patient’s responsibility.

Cancellations/Missed Appointments:

Appointment reminders by phone or email can be sent the day prior to the scheduled appointment to help patients avoid missing appointments. Please let Dr. Evans know if you prefer to be reminded by phone or email.

APPOINTMENTS MADE AND NOT KEPT ARE FULLY BILLED TO THE PATIENT. Insurance
companies will not reimburse for any portion of fees for missed appointments. 

PATIENT MUST GIVE CANCELLATION NOTIFICATION AT LEAST 2 BUSINESS DAYS PRIOR TO THE SCHEDULED APPOINTMENT TIME. If an appointment is cancelled less than 2 business days before the scheduled appointment time, the patient will be billed the full fee of the scheduled appointment ($200 for a 45 minute visit, $150 for a 25 minute visit). Insurance companies will not reimburse late-cancellation fees.

PLEASE NOTE THAT PRACTICE STANDARDS REQUIRE ALL PATIENTS TO BE SEEN AT
LEAST ONCE EVERY THREE MONTHS.

Communication:

IF A PATIENT IS EXPERIENCING A LIFE-THREATNING OR MEDICAL EMERGENCY, THEY SHOULD GO TO THE NEAREST EMERGENCY ROOM OR CALL 911 FOR ASSISTANCE.

For billing questions, please call (727) 800-2332.

Primary methods for contacting Dr. Evans at Middle Path Psychiatry include the main office number (720) 502-5670 and the Secure Messaging feature of the Valant patient portal. Messages sent using either of these primary methods of contact are retrieved throughout the day, Monday through Friday and are usually returned the same or following business day.

Telephone conversations should generally last no more than 5 minutes. If a matter needs to be discussed for longer than 5 minutes, the patient should schedule an appointment with Dr. Evans. Calls lasting longer than 5 minutes will be billed to the patient on a prorated basis, minimum $25. Insurance companies will not reimburse fees for telephone conversations.

Secure Messaging via the patient portal should be reserved for limited purposes such as confirming appointment times, requesting medication refills and other short queries which can be answered briefly. Clinical questions will not be addressed via Secure Messaging in the patient portal. Patients will receive clinical measures and questionnaires via the patient portal which must be completed prior to the next scheduled appointment. Patient will set up their patient portal access with Dr. Evans when scheduling their first appointment.

Please note the office fax line is confidential and should not be given out to pharmacies. 

I HAVE BEEN INFORMED OF AND READ THE PRECEDING INFORMATION AND AGREE TO IT.

PLEASE REVIEW CAREFULLY AND SIGN ACKNOWLEDGEMENT OF RECEIPT FORM.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a Federal program that requests that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, the right to understand and control how your personal health information ("PHI") is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we prepared this explanation of how we are to maintain the privacy of your health information and how we may disclose your personal information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operation.

• Treatment means providing, coordinating, or managing health care and related services by one or more healthcare providers. An example of this is a primary care doctor referring you to a specialist doctor.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collections activities, and utilization review. An example of this would include sending your insurance company a bill for your visit and/or verifying coverage prior to an office visit.
• Health Care Operations include business aspects of running our practice, such as conducting quality assessments and improving activities, auditing functions, cost management analysis, and customer service. An example of this would be new patient survey cards.
• The practice may also be required or permitted to disclose your PHI for law enforcement and other legitimate reasons. In all situations, we shall do our best to assure its continued confidentiality to the extent possible.

We may also create and distribute de-identified health information by removing all reference to
individually identifiable information.

We may contact you, by phone or in writing, to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

The following use and disclosures of PHI will only be made pursuant to us receiving a written authorization from you:

• Most uses and disclosure of psychotherapy notes;
• Uses and disclosure of your PHI for marketing purposes, including subsidized treatment and health care operations;
• Disclosures that constitute a sale of PHI under HIPAA; and
• Other uses and disclosures not described in this notice.

You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your prior authorization.

You may have the following rights with respect to your PHI:

• The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to honor a request restriction except in limited circumstances which we shall explain if you ask. If we do agree to the restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of Protected Health Information by alternative means or at alternative locations.
• The right to inspect and copy your PHI.
• The right to amend your PHI.
• The right to receive an accounting of disclosures of your PHI.
• The right to obtain a paper copy of this notice from us upon request.
• The right to be advised if your unprotected PHI is intentionally or unintentionally disclosed.

If you have paid for services "out of pocket", in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we will accommodate your request, except where we are required by law to make a disclosure.

We are required by law to maintain the privacy of your Protected Health Information and to provide you the notice of our legal duties and our privacy practice with respect to PHI.

This notice if effective as of February 1, 2018 and it is our intention to abide by the terms of the Notice of Privacy Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provision effective for all PHI that we maintain. We will post and you may request a written copy of the revised Notice of Privacy Practice from our office.

You have recourse if you feel that your protections have been violated by our office. You have the right to file a formal, written complaint with office and with the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Feel free to contact the Practice Compliance Officer (Dr. Joshua Evans at 720-502-5670) for more information, in person or in writing.

 

I hereby acknowledge receipt of Middle Path Psychiatry's Notice of Privacy Practices with respect to the patient.

As required by the Health Insurance Portability and Accountability Act of 1996, Middle Path Psychiatry may not use or disclose your health information except as provided in our Notice of Privacy Practices without your authorization. Your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information described herein.

1. Patient Information

2. RECORDS FOR RELEASE (Please mark the records to be released)

3. PURPOSE

4. RELEASE RECIPIENT INFORMATION

Name: Middle Path Psychiatry / Dr. Joshua Evans
Current Address (incl. apt or suite #): 950 South Cherry Street, Suite 420
City, state, ZIP Code: Denver, CO 80246
Phone: (720) 502-5670
Fax: (720) 502-5679

I understand that I may revoke this authorization at any time by providing a written revocation statement that is signed and dated after the date on this form. I further understand that any such revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization. I understand that this authorization will automatically expire 1 year from the date of this document unless a written request is provided for a different expiration date. A copy of this authorization shall act as the original.

By signing, I acknowledge that I have provided accurate information and agree to the terms and conditions of this document.

E-Signature Terms

By selecting the "Submit" button, I am signing this agreement electronically. I agree that my electronic signature is the legal equivalent of my manual signature. 

Indicate your consent to the terms and conditions of this agreement by drawing your signature in the box provided and clicking the "Submit" button at the end of this form.