A. CONSENT FOR TREATMENT & USE OF TELEMEDICINE

I voluntarily consent to psychiatric evaluation and treatment by Lifetime Insight, which may include psychotherapy, medication management, lab testing, and other appropriate services. I understand:

• I may discontinue treatment at any time.
• Treatment is confidential except in cases where the law requires reporting (such as risk of harm or abuse).
• No guarantees are made regarding the results of treatment.

Telemedicine involves the use of secure electronic communication for evaluation, therapy, and medication management. This may include:

• Medical records, images, labs, live video/audio
• Device output or photos/video of the patient
• Sound recordings, billing/scheduling data

Telemedicine uses secure systems to protect confidentiality, but I understand there are risks including technical failures, unauthorized access, or delays in treatment. I understand:

• I can withdraw consent to telemedicine at any time.
• I may need in-person exams for some conditions.
• Others (e.g. tech support) may assist, and I can request they not be present.
• In emergencies, the telemedicine physician will coordinate with a local provider.
• Telemedicine is not a substitute for emergency care.

By signing, I agree to treatment via telemedicine or in person. I have had the chance to ask questions, understand the risks and benefits, and choose to proceed.

B. APPOINTMENTS, FEES, & PAYMENT POLICIES

Appointments

• All appointments begin via telehealth unless an in-person visit is required for medication reasons.
• First appointments are 55 minutes; follow-ups range from 10–45 minutes.
• Patients must be seen at least once every 3 months.
• Use our virtual waiting room: https://lifetimeinsight.doxy.me 

Insurance & Out-of-Network

• You’re responsible for notifying us of any insurance changes.
• If your plan denies coverage (e.g. deductible, coinsurance, out-of-network, or mental health carve-outs), you’ll be charged our self-pay rate.

Cash/Self-Pay Rates (due in full at time of service)

• Initial Visit (55 min): $475
• Psychotherapy (55 min): $475
• Extended Visit (45 min): $400
• Extended Med-Check (up to 25 min): $300
• Brief Med-Check (up to 15 min): $225

We can provide a superbill if you’d like to seek reimbursement from your insurance.

No-Shows & Late Cancellations

• Cancelling with less than 1 business day (24 hours) notice or missing your appointment results in a late cancel/no-show fee:
  • $400 for 45–55 min
  • $250 for 25 min
  • $175 for 15 min
• If you're 5+ minutes late to a short appt or 10+ minutes late to a long one, it's treated as a no-show.
• Fees are charged automatically to your card on file. No new appointments will be scheduled until fees are paid.

Payment & Card Authorization

• We accept credit cards, Zelle, and PayPal: pay@lifetimeinsight.com
• A valid credit card must be kept on file. It will be used for:
  • Copays/deductibles
  • No-show/late fees
  • Unpaid balances >30 days
• Failed payment attempts or unpaid balances may result in suspension of care or collections.

Collections

• Accounts overdue by 90+ days will be referred to collections.
• If you're struggling to pay, request a payment plan (usually via PayPal). We’ll do our best to work with you if you show good faith effort.

Non-Covered Services
Some services are not covered by insurance and are billed directly to you at $475/hour, in 15-minute increments. These include:

• Letters for landlords, schools, or disability
• Phone calls over 5 minutes
• Reports or forms requested outside of standard visits

We do not complete disability paperwork unless you’ve been a patient for 6+ months and 5+ visits, and even then it is at the doctor’s discretion.

We do not provide documentation for:

• Emotional Support Animals (ESA)
• Disability for the state of California

C. PRESCRIPTION & CONTROLLED SUBSTANCE POLICY:

• Always tell us and your pharmacy about all medications you're taking—including over-the-counter or supplements—to avoid harmful interactions.

• Use one pharmacy for all prescriptions unless you notify us otherwise. We do not work with local CVS, but CVS Caremark (mail-order) is acceptable after 3 months of stability.

• Refills are typically processed within 2–3 business days. Please request early. We do not handle urgent refill requests.

Controlled medications (like stimulants, benzos, sleep aids):

• Require regular visits—at least every 90 days for stimulants.
• May require urine drug screens or pill counts.
• Must be filled in your home state unless discussed in advance.
• Lost/stolen meds require a police report—no exceptions.
• Doctor shopping is illegal. Getting the same med from another prescriber without telling us will result in dismissal from the practice.

D. COMMUNICATION, BEHAVIOR & TERMINATION POLICY:

We communicate primarily through a secure patient portal for messages, refill requests, forms, and appointment issues. Responses are typically sent within 1–2 business days. Please do not use email, text, or phone calls for emergencies.

Brief phone calls may be returned by staff within 1 business day. Non-urgent matters may be addressed at your next visit or through the portal.

We expect respectful communication and behavior at all times. Abuse, harassment, repeated no-shows, or failure to meet financial obligations may result in discharge from the practice.

Patients may be dismissed for:

• Three or more no-shows/late cancellations
• Outstanding balances over 90 days
• Inappropriate behavior or communication
• Failure to follow up regularly
• Loss of trust or poor therapeutic fit

If terminated, you will receive notice through the portal, including help with transferring care and refills, if needed.

 

E. ADDITIONAL NOTICES & ACKNOWLEDGEMENTS

Policy Updates
We update our forms yearly and may revise this notice at any time. The most recent signed version will apply to your care. Changes do not require additional agreement unless stated.

Open Payments Database
The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at:
👉 https://openpaymentsdata.cms.gov

HIPAA Notice of Privacy Practices
I have read and agree to the Notice of Privacy Practices (“HIPAA”) posted here:
👉 https://tinyurl.com/LI-HIPAA