Integrative Behavioral Health & Healing Practice

If you choose not to or are unable to upload your card/s here, please make sure to email copies to info@integrativebehavioralhp.com or text them to 984-288-0880. We require copies of these cards to be able to schedule you with one of our providers.

*Note: Functional psychiatry as a stand-alone service is not covered by insurance and will be self-pay. Any lab work ordered that is related to functional psychiatry is also typically not covered by insurance.

Only certain providers offer functional psychiatry. Please confirm that the provider you are requesting has this option. 

FEES AND INSURANCE INFORMATION

All new patient appointments are 60 minutes. The fee for self-pay new patients is $400.00. The fee for self-pay of a 40 minute follow up appointment with psychotherapy is $250.00. The fee for self-pay of a 30-minute follow up appointment is $200. The fee for self-pay of a 20 minute follow up appointment is $175.00. The fee for self-pay of CNS VS testing is $400.00. At this time, we are currently in network with Aetna, BCBS*, Cigna (EverNorth), Medcost, Medicare, Multiplan, and United (Optum) insurance plans. As a courtesy to you, we will file claims for your sessions electronically; however, payment of all applicable co-pays, co-insurances and deductibles are required prior to the scheduled appointment time. IBHHP will charge for upcoming appointments approximately 24 hours in advance of the appointment.
We will not be able to file claims with your insurance company unless you provide complete and accurate information about your insurance. It is your responsibility to ensure that we have the correct information and that you promptly inform the practice of any changes in your coverage. If, for any reason, your insurance company does not reimburse Integrative Behavioral Health & Healing Practice for services rendered, you will be responsible for those charges. Attempts to collect this balance will be made for 30-90 days past due. Any balances that age past 90 days will be transferred to a collection agency.

*While we are in network with nearly all BCBS plans, we do not accept BlueHome/UNC Health Alliance. This is a restricted plan that would be out of network. Patients with this plan will be self-pay and claims will not be submitted.

PAYMENT INFORMATION

All co-pays, co-insurances and deductible payments will be processed through XPressPay through First Citizens Bank, a secure, online payment platform. The amount you owe for your visit will be automatically deducted approximately 24 hours prior. At the time of scheduling your first visit you will be required to provide the debit or credit card that you wish to be stored for payment purposes. If for any reason you do not have an up-to-date payment method on file and a successful payment has not been made for your appointment, please note your appointment will be cancelled and may result in a fee.

NO-SHOWS & LATE CANCELLATIONS

All cancellations need to be made by phone call or email more than 24 business hours prior to your appointment time. This includes weekends if your appointment is on a Monday. If you fail to cancel your appointment with more than 24 business hours notice, you will be charged a cancellation fee of $400 for new patient appointments and $175-$250 for office visits, depending upon the allotted time for your appointment. Insurance companies will not pay for missed appointments and you will be held responsible for the full (above) cost of the missed appointment. Additionally, if you are more than 10 minutes late for your appointment, you will have to be rescheduled and the late cancellation fee will be applied to the card on file.

EMERGENCIES

For after hour emergencies ONLY you may contact our on-call provider on weekends at the following number (984) 288-0880. Please note a charge will be applied for contacting the on-call provider.

If you are experiencing an emergency, please call 911 or go to the nearest emergency room. Emergency situations include serious psychiatric medication reactions or risk of harm to oneself or someone else.

PRESCRIPTION REFILLS

Refills of medication are usually written at the time of your appointment. If you are in need of a refill between appointments, please contact your pharmacy, and they will fax a refill request allowing 72 hours for refills to be completed. If it is a refill for a class II controlled substance (ADHD stimulants) call the office at 984- 288-0880 and request a refill. Refills are not considered an emergency and will be handled during regular business hours of 7:40am and 4pm, within 72 business hours.

If you contact the after-hours emergency on call provider on weekends for a refill a charge will be applied to your card. All controlled substance refills require the patient to have been seen in an appointment within the past 3 months. The patient will not be granted a refill until seen in an appointment past this time. It is the responsibility of the patient to ensure following up to appointments.

TREATMENT OF STAFF

Staff have the right to work in a safe and secure environment and we as employers have the legal responsibility of providing that environment. The Practice will not tolerate:

• Verbal abuse to staff which prevents them from doing their job or makes them feel intimidated or unsafe
• Threats of violence or actual violence to any member of the Practice

Our Practice staff aim to be polite, helpful, and sensitive to all patients’ individual needs and circumstances. They would respectfully remind patients that very often staff could be confronted with a multitude of varying and sometimes difficult tasks and situations, all at the same time. The staff understand that ill patients do not always act in a reasonable manner and will take this into consideration when trying to deal with a misunderstanding or complaint.

However, aggressive behavior, be it violent or abusive, will not be tolerated and may result in you being immediately terminated from the practice.In order for the practice to maintain good relations with their patients the practice would like to ask all its patients to read and take note of the occasional types of behavior that would be found unacceptable:

• Using bad language or swearing at practice staff
• Any physical violence towards any member of the Primary Health Care Team or other patients
• Verbal abuse towards the staff in any form including verbally insulting the staff
• Racial abuse and sexual harassment will not be tolerated within this practice
• Persistent or unrealistic demands that cause stress to staff will not be accepted. Requests will be met wherever possible and explanations given when they cannot
• Obtaining drugs and/or medical services fraudulently
• Treat your provider and their staff courteously at all times.

Your signature below indicates that you have read this agreement and agreed to all of its terms. You understand that if the terms of this agreement are violated, your treatment in this practice may require termination. Your signature also serves as an acknowledgement that you have received the HIPAA Notice of Policies and Practices described above if you have requested it or agreed to review it on my website.

LIMITS OF CONFIDENTIALITY

Treatment is confidential, with the below stated exceptions.Duty to Warn: medical providers are mandated by law to disclose pertinent information discussed in appointments if the patient:

1. Has intent or plan to harm another person. We are required to inform the intended victim and notify legal authorities.
2. When there is reasonable cause to believe child/elder abuse or neglect has occurred.
3. When an emergency situation requires sharing of information.
4. When required for insurance billing purposes.
5. When a court order is received.

By signing, I acknowledge that I have read, understood and agree to the items contained in this document. If the patient is a minor, lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.

Thank you for your interest in Telemedicine. Please read our office policies for conducting Telemedicine.

• Integrative Behavioral Health & Healing Practice accepts and bills insurance for Telemedicine visits.
• Benefit investigation is done by the administrative staff for general mental health benefits. It is the patient's responsibility to know coverage for Telemedicine. Self-pay rates will apply should the patient not have Telemedicine/Telehealth coverage.
• Self-pay Telemedicine visits are $175 for a 20 minute follow up, $200 for a 30 minute follow up, $250 for a 40 minute follow up, and $400 for a new patient visit.

DURING YOUR SESSION:

• The provider will introduce themself.
• You may be asked to confirm the state you are in and the state where you live. You may also need to show a photo ID.
• Patients under the age of 16 will need to be accompanied by a parent or guardian for the duration of the video session.
• A report of the session will be placed in your medical record. You can get a copy from your provider.
• All laws about the privacy of your health information and medical records apply to Telemedicine. These laws also apply to the video, audio, and photo files that are made and stored.

TELEMEDICINE POLICIES:

• The provider has the discretion to determine whether or not to continue Telemedicine appointments.
• Patients are required to be ready and available at their appointment time. Checking in tardy, missing or canceling less than 24 business hours will result in a rescheduling fee– $175-$250 for follow up visits and $400 for new patient visits.
• The card on file will be charged 24 hours prior to your appointment prior to initiating your Telepsych visit.
• Your provider uses HIPAA compliant software for Telemedicine.
• Not having Wifi or having a poor connection due to using a data plan is considered missing your appointment.

I certify that I have read, understand, and agree to follow the information provided above regarding telemedicine. I hereby give my informed consent for the use of telemedicine in my medical care.

If the patient is a minor, lacks legal capacity or is unable to sign, an authorized personal representative may sign this form.

PURPOSE

IBHHP is committed to the safe, responsible, and evidence-based prescribing of controlled substances. Due to the potential risks associated with these medications, including misuse, dependence, and diversion, the following policy applies to all prescribers within the practice.

Prescribing Standards

Controlled substances will only be prescribed when clinically appropriate and in accordance with federal and state regulations. Providers are expected to use sound clinical judgment and consider non-controlled alternatives when possible.

Evaluation and Documentation

A comprehensive evaluation must be completed prior to initiating any controlled substance. This includes:
• Review of medical and psychiatric history
• Assessment of current symptoms and functional impairment
• Evaluation of risk factors for misuse or diversion

All prescribing decisions must be clearly documented in the patient’s medical record.

Prescription Drug Monitoring Program (PDMP)

Prescribers are required to review the North Carolina Controlled Substances Reporting System (CSRS) prior to initiating controlled substances and periodically thereafter, in accordance with state guidelines.

Controlled Substance Agreements

Patients prescribed controlled substances may be required to sign a Controlled Substance Patient Agreement outlining:
• Medication use expectations
• Refill policies
• Prohibition of sharing or selling medication
• Agreement to use a single pharmacy when possible

Prescription Limits

Controlled substances will be prescribed in no greater than a 30-day supply, unless deemed appropriate by the provider. Additional refills or extensions require provider evaluation and approval. Patients are expected to follow up as directed to ensure continuity of care.

Refill Policy for Controlled Substances

Controlled substances are prescribed with the expectation that they will be taken exactly as directed.
• Early refills are not permitted. Requests for early refills will generally be denied.
• Lost, stolen, or damaged medications will not be replaced.
• Running out of medication early due to taking more than prescribed is not a valid reason for an early refill.
• Refill requests must be submitted during normal business hours and within the timeframe established by the practice.
• Providers do not guarantee same-day processing of refill requests.
• Urine drug screens may be required at the provider’s discretion at any time. Refusal to complete a requested urine drug screen may result in termination from the practice.
Exceptions to this policy are rare and will only be considered at the sole discretion of the provider in extenuating circumstances. Repeated requests for early refills or reports of lost or stolen medication may result in discontinuation of controlled substance prescribing.

Follow-Up Requirements

Patients prescribed controlled substances must be seen regularly for monitoring. Patients must be seen for follow-up visits at least once every three (3) months to receive a refill.

Telehealth Prescribing

Controlled substances may be prescribed via telehealth only when compliant with current federal and state regulations. In-person evaluations may be required when clinically indicated.

Discontinuation of Medication

Providers reserve the right to taper or discontinue controlled substances if:
• There is evidence of misuse, diversion, or noncompliance
• The medication is no longer clinically indicated
• The patient does not adhere to treatment recommendations

Safety and Compliance

Prescribers must comply with all applicable laws, including DEA regulations and North Carolina prescribing requirements.

To help ensure your safety and the safe use of controlled medications, we ask that you review and agree to the following:
• I understand that controlled medications are prescribed in limited quantities (typically no more than a 30-day supply unless approved by provider) and require regular follow-up appointments.
• I understand that I must be seen for follow-up visits at least once every three (3) months to receive a refill.
• I agree to take my medication exactly as prescribed and will not change the dose without speaking to my provider.
• I understand that early refills are not routinely provided, and I am responsible for taking my medication as directed so that it lasts until my next refill.
• I understand that lost, stolen, or damaged medications may not be replaced.
• I agree not to share, sell, or misuse my medication in any way.
• I understand that urine drug screens may be required at the provider’s discretion at any time. Refusal to complete a requested urine drug screen may result in my termination from the practice.
• I agree to use one pharmacy when possible and understand that my provider may review prescription monitoring databases as part of my care.
• I agree to attend scheduled follow-up appointments as directed by my provider.

I understand that failure to follow this agreement may result in changes to my treatment plan, including discontinuation of controlled medications.By signing below, you are acknowledging that you have received and reviewed a copy of the Controlled Substances Prescribing Policy.

PLEASE REVIEW THE FOLLOWING INFORMATION CAREFULLY. THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

Protecting Your Personal and Health Information

Integrative Behavioral Health & Healing Practice is committed to protecting the privacy of its patients’ personal and health information. Applicable federal and state laws as well as ethical standards require us to maintain the privacy of our patients’ personal and health information. This Notice explains our practice’s privacy practices and your rights concerning your personal and health information. In this Notice, your personal and health information is referred to as “protected health information (PHI)” and includes information regarding your healthcare and treatment.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all PHI that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change the Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. The Notice is also available electronically on our website at all times.

We protect your health information by:
• Treating all of your health information that we collect as confidential.
• Stating confidentiality policies and practices in our medical and clinic staff handbooks as well as disciplinary measures for privacy violations.
• Restricting access to your health information only to those Integrative Behavioral Health & Healing Practice staff who need to know your health information in order to provide our services to you.
• Only disclosing your health information that is necessary for an outside service company to perform its function on our behalf, and the company has by contract agreed to protect and maintain the confidentiality of your health information.
• Maintaining physical, electronic, and procedural safeguards to comply with regulations and standards guarding your health information.

Uses And Disclosures of Health Information

Integrative Behavioral Health & Healing Practice may use or disclose PHI for the purposes of treatment, payment, and health care operations, described in more detail below, without obtaining written authorization from you.

Treatment -Integrative Behavioral Health & Healing Practice may use and disclose PHI while providing, coordinating, or managing your medical treatment, including the disclosure of PHI to another physician or other healthcare provider providing treatment to you.

Payment -Integrative Behavioral Health & Healing Practice may use and disclose PHI to bill and obtain payment for health care services we provide to you, including health insurance companies. PHI may also be disclosed to Integrative Behavioral Health & Healing Practice business associates, such as billing companies, claims processing companies, and others that assist in processing health claims.

Healthcare Operations -Integrative Behavioral Health & Healing Practice may use and disclose PHI in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

For Sharing PHI Among Integrative Behavioral Health & Healing Practice And Its Health Professional Staff -Integrative Behavioral Health & Healing Practice and the providers who are members of the Integrative Behavioral Health & Healing Practice medical staff work together in an organized health care arrangement to provide medical services to you when you are a patient at Integrative Behavioral Health & Healing Practice. Integrative Behavioral Health & Healing Practice and the members of its medical staff as well as administrative staff may share with each other PHI that they collect from you necessary to carry out the treatment, payment and health care operations relating to the provision of care to you as a patient of Integrative Behavioral Health & Healing Practice.

Disclosure to Health Information Exchanges -Integrative Behavioral Health & Healing Practice participates in the North Carolina Health Information Exchange Network, called NC HealthConnex, which is operated by the North Carolina Health Information Exchange Authority (NC HIEA). We will share your protected health information, or PHI, with the NC HIEA and may use NC HealthConnex to access your PHI to assist us in providing health care to you. We are required by law to submit clinical and demographic data pertaining to services paid for with funds from North Carolina programs like Medicaid and State Health Plans. We may also share other patient data with NC HealthConnex not paid for with state funds. If you do not want NC HealthConnex to share your PHI with other health care providers who are participating in NC HealthConnex, you must opt out by submitting a form directly to the NC HIEA. Forms and brochures about NC HealthConnex are available online at NCHealthConnex.gov. Again, even if you opt out of NC HealthConnex, we still must submit your PHI if your health services are funded by State programs. Your patient data may also be exchanged or used by the NC HIEA for public health or research purposes as permitted or required by law. For more information on NC HealthConnex, please visit NCHealthconnex.gov/patients.

Your Authorization -In addition to our use of PHI for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose, if you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Persons Involved in Care -Integrative Behavioral Health & Healing Practice must disclose PHI to you, as described in the Patient Rights section of this Notice. We may disclose PHI to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Integrative Behavioral Health & Healing Practice may use or disclose PHI to notify, or assist in the notification of (including, identifying or location) a family member, your personal representative or another person responsible for your care, or your location, your general condition, or death. If you are present, then prior to use or disclosure of PHI, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose PHI based on a determination using our professional judgment disclosing only PHI that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up sample medications, forms, or other similar forms of health information.

Marketing Health-Related Services -Integrative Behavioral Health & Healing Practice will not use PHI for marketing communications without your written authorization.

Integrative Behavioral Health & Healing Practice may use or disclose PHI for circumstances that do not require your authorization. Prior to disclosing PHI, we will evaluate each request to ensure that only necessary information will be disclosed. Those circumstances include disclosures in relation to:

Required by Law -Integrative Behavioral Health & Healing Practice may use or disclose PHI when we are required to do so by law.

Harm to Self or Others -Integrative Behavioral Health & Healing Practice may disclose your PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose PHI to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security -Integrative Behavioral Health & Healing Practice may disclose to military authorities the PHI of Armed Forces personnel under certain circumstances. We may disclose to authorize federal official PHI required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of PHI of inmate or patient under certain circumstances.

Appointment Reminders -Integrative Behavioral Health & Healing Practice may use or disclose PHI to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

You have the following patient rights regarding your PHI:

Generally, you have the right to inspect and copy your PHI that Integrative Behavioral Health & Healing Practice maintains, provided that you make your request in writing. Within thirty (30) business days of receiving your request (unless extended by an additional thirty (30) days), Integrative Behavioral Health & Healing Practice will inform you of the extent to which your request has or has not been granted. In some cases, Integrative Behavioral Health & Healing Practice may provide you with a summary of the PHI you request if you agree in advance to such a summary and any associated fees. If you request copies of your PHI or agree to a summary of your PHI, Integrative Behavioral Health & Healing Practice may impose a reasonable fee to cover copying, postage, and related costs. If Integrative Behavioral Health & Healing Practice denies access to your PHI, it will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If Integrative Behavioral Health & Healing Practice does not maintain the PHI you request and if it knows where that PHI is located, it will tell you how to redirect your request. Any requests in relation to PHI must be submitted in writing via mail, email, or fax Integrative Behavioral Health & Healing Practice.

You have the right to request that Integrative Behavioral Health & Healing Practice place additional restrictions on the use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except in emergency situations.

You have the right to request that we amend your PHI. (Your request must be in writing, and it must explain why the information should be amended.) Integrative Behavioral Health & Healing Practice reserves the right to and may deny your request under certain circumstances. Integrative Behavioral Health & Healing Practice may deny your request if the information was not created by this agency (unless you prove the creator of the information is no longer available to change the information), the information is not part of the records used to make decisions about you, we believe the information is correct and complete, or you do not have the right to see and copy the record.

You have the right to request that we communicate with you about your PHI by alternative means or alternative locations.

Questions and Complaints

If you want more information about Integrative Behavioral Health & Healing Practice privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI or in response to a request you made to amend or restrict the use or disclosure of your PHI or to have us communicate with you by alternative means or at alternative locations, you may contact our Privacy Official. All complaints must be submitted in writing. Contact information is provided below. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Privacy Officer: Emily Holton
Telephone: (984) 288-0880
Fax: (984) 217-1701
Email: eholton@integrativebehavioralhp.com
Address: 124 E Fisher Ave Greensboro, NC 27401

Integrative Behavioral Health and Healing Practice is required by law to maintain the privacy of and provide individuals with the attached Notice of our legal duties and privacy practices with respect to protected health information (PHI). The law does not require you to sign the “Notice of Privacy Practices Acknowledgement of Receipt.” Signing does not mean that you have agreed to any special uses or disclosures (sharing) of your health records and a separate “Authorization to Release Medical Information” release form must be completed for agreed uses or disclosures of PHI. Refusing to sign the acknowledgement does not prevent Integrative Behavioral Health and Healing Practice from using or disclosing health information as HIPAA permits. If you receive this Notice on our Web site or by email, you are entitled to receive this Notice in written form.By signing below, you are acknowledging that you have received and reviewed a copy of the Notice of Privacy Practices.

Our office requires that a credit card be kept on file for payment. The information below is confidential in accordance with HIPAA compliance rules. Your medical insurance plan generally pays only a portion of medical services. Different plans pay different amounts, and while we can estimate the amount, we never have the exact amount until the medical benefit payment arrives. You are responsible for the portion your medical insurance plan does not cover at the time of service. This would include co-payments, co-insurance and annual deductibles. This office will electronically submit your insurance claim the day services are rendered. However, if payment is not received by your medical insurance plan within 30 days or if there is a balance after payment is received, the remaining balance will be charged to your credit card.

I authorize Integrative Behavioral Health & Healing Practice, PLLC to charge my credit card 24 hours prior to my appointment for my insurance copay/deductible or post-appointment for any balance remaining on my account after the medical insurance plan has paid their portion. If I am an uninsured patient, I authorize payment for the self-pay rate for visits completed during that time. I understand that this form is valid for all transactions for one year unless I cancel the authorization through written notice to Integrative Behavioral Health & Healing Practice, PLLC. I also realize that I may not get pre-notification of charges.

Please note: There is a small processing fee for each credit card transaction.

If the patient is a minor, lacks legal capacity, is unable to sign, or provide a card to keep on file, an authorized personal representative may complete and sign this form.