Patient Agreement. Welcome to Community Psychiatry. Treatment - What to Expect. Children and Appointments

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1 Welcome to Community Psychiatry Our dedicated medical providers and staff are committed to providing the highest quality medical care for each and every patient. Set forth below is our Patient Agreement, which establishes guidelines for your participation in treatment with us. Please read the following paragraphs carefully and ask front desk staff if you have any questions. If, after reading and considering the terms of this Patient Agreement, you agree to everything set forth below, please sign where indicated. Treatment - What to Expect Minors: The initial evaluation for your child involves two sessions that are approximately minutes each. The purpose of these sessions is to obtain a detailed history for an accurate assessment of your child s difficulties. Many times, your child s doctor may need to obtain collateral information from your child s other providers and school before generating a more definitive diagnosis and/or recommendations. Adults: Your initial evaluation involves one, approximately minute session. Many times your physician may need to obtain collateral information from your other providers before generating a more definitive diagnosis and/or recommendations. All: Following the initial evaluation, your physician (or your child s physician) will discuss the assessment with you and make recommendations regarding medication and/or psychotherapy. If your doctor determines medication is needed, our staff will schedule follow up sessions which usually occur every one to two weeks during the initial phase of treatment. In these sessions your physician will need to carefully monitor your response (or your child s response) to medication and side effects which sometimes occur. These follow up sessions typically last minutes, although they may take somewhat longer in the early stages of treatment. The discussions between you and your physician (or between your child and his/her physician) and the physician s clinical observations become the basis for choosing medication. For some situations and some medications, the physician may request blood tests or EKG prior to starting medication. Children and Appointments We kindly ask that your children do not accompany you to appointments unless they are seen as a patient, or are specifically requested to attend by your doctor. Please note that we cannot have children waiting in our waiting area without the supervision of a parent, guardian, or caretaker. Page 1 of 11

2 Cancellation Policy We reserve your appointment time specifically for you and you alone. For this reason, our office charges for cancellations without 2 business days notice. If you cancel or reschedule a visit without two business days notice, the cancellation fees are as follows: Initial appointment $225 Follow-up appointment $125 for minutes Follow-up appointment $225 for minutes Psychotherapy appointment $100 We also understand that your time and money is valuable. For this reason, our office staff will always try to call and remind you about each appointment as a courtesy. Late Arrivals If you arrive late for your appointment and your doctor determines that there is enough time remaining, he or she will be able to see you only for the allotted time left of your scheduled appointment. At such times, it may be necessary to schedule an additional appointment to allow you and the doctor to have sufficient time to address your treatment concerns. Same Day Appointments Most insurance companies do not pay for two mental health visits on the same day. If you schedule visits with your psychiatrist on the same day that you meet with your psychotherapist, you may be expected to pay for one of these visits. Gastric Bypass Evaluation Blue Cross is the only insurance company that will pay a small portion of the gastric bypass evaluation. Please check in with our staff for a breakdown and explanation of what the cost of today s visit will be. Emergencies and Urgent Consultations For your benefit, a covering physician will be available each day after office hours until 9 p.m. to discuss problems with medications via phone. The covering psychiatrist can be reached by calling our call center whose number will always be listed on our voice mail message. For emergencies, do not call our offices. Please call 911 or go directly to the emergency room at the nearest hospital. Page 2 of 11

3 Starting Medications Our psychiatrists typically evaluate adults for one session and children for two sessions before determining whether medication is indicated for care. While parents are understandably concerned about getting treatment as soon as possible, the decision to start a medication often cannot be made during the first session and is usually deferred until your second meeting to allow your doctor the necessary time for a complete history, examination of your child, and reviewing any additional medical or school records pertinent to your child s care. Forms and Documents All medical forms (such as disability forms, school forms, workers compensation forms, etc.) are completed by your psychiatrist while he or she meets with you in your session. Please notify your psychiatrist at the beginning of each session if you have forms to be filled out. Regular Attendance & Prescription Refills Regular attendance at appointments is a critical part of your care/your child s care. Our office does not routinely refill prescriptions over the phone. If you need a refill before your next scheduled appointment please call one week prior to running out of your medication. If you (or your child) misses an appointment and are running out of medication, we will normally insist that you (or your child) see one of our psychiatrists who will refill your medication. Please do not call for medication refills during the weekends unless you have run out of medication. Emergency weekend prescriptions when necessary are never given for more than seven days dosing. In addition, please note the following: ***Patients needing a refill of a controlled substance during on-call hours***: No more than a 5 day supply of your medication will be refilled by the on-call physician to cover you until you are able to be seen by your treating physician. On-call physicians will never supply more than 5 days worth of a controlled substance medication. The covering physician must be provided with the pharmacy s name and phone number where you last received this medication. If the covering physician is unable to determine through pharmacy records that you are currently taking this medication then the physician may not be able to refill your medication. ***For patients that are on stimulant medications***: Pharmacies will not accept prescriptions for stimulants that are called in or faxed. Prescriptions for stimulant medications must be written on a secure paper and given during an appointment. Page 3 of 11

4 Mail Order Prescriptions Our physicians would like to assist you in benefiting from mail order prescription services as long as it does not interfere with the quality of your care. For this reason, we will expect you to keep the recommended appointments scheduled by your physician. Almost all patients are seen at least monthly and we will not provide 90 day prescriptions if you are unwilling to keep your recommended appointments. About Your Prescriptions and Visits The relationship between the psychiatrist and his/her patient is a partnership, the goal of which is the well-being of the patient s mental health. We have developed the following procedures and expectations over time as we have found that they ensure that you or your child will have the best response with the least problems on prescribed medication. Always discuss any changes or side effects in medications with your physician. Never stop or change the dose of a medication without contacting your doctor. When medications are stopped, they must either be stopped gradually or be replaced with another more effective medication prescribed by a physician. Suddenly stopping medication can cause medical problems. For this reason, never allow yourself to run out of medication. Be sure to keep your appointments. Although your physician will provide you with adequate medication until your next visit, cancelled or missed visits can prevent you from having an adequate supply of medication and makes it difficult for your psychiatrist to properly monitor your progress and help with complications. If you do cancel or miss a visit, be sure to reschedule your next visit before you run out of medication. In general, we will insist that you see your physician before refilling your medication (see above). If side-effects or problems occur with your medication, contact our office to arrange an urgent visit with your psychiatrist. Although regularly scheduled visits with your doctor may at times feel burdensome, this commitment insures that you or your child will receive the highest level of care, which you deserve. Request for Disability or Injured Worker Status When your disability is based on physical injuries, your primary care physician will be responsible for assessing your disability status. In those cases where your disability is based on a psychiatric illness, our psychiatrists will assist with disability paperwork. Occasionally, there may be a disagreement between you and your psychiatrist regarding your disability status. In such situations, our highest priority is protecting your relationship with your treating psychiatrist. Page 4 of 11

5 For this reason, whenever such a disagreement occurs, we will arrange for you to see a forensic psychiatrist to meet with you, review your records and make an independent decision regarding your disability status. This psychiatrist would then take over the disability process in order to preserve your working relationship with your treating psychiatrist at Community Psychiatry. Parity and Non-Parity Benefits In the State of California any patient with a parity diagnosis by law must receive insurance coverage for that diagnosis which is equal to (at parity) with their medical coverage. Unfortunately, some insurance companies will not cover Attention Deficit Disorder (ADD/ADHD) for adults, even though it is typically covered as parity for children. If your insurance company determines that your diagnosis is not parity, then you may have a higher co-pay, deductible, or a limit to the number of covered sessions with your psychiatrist. At the time of your visit, your psychiatrist will have no way of knowing ahead of time whether your insurance company will provide parity coverage for Attention Deficit Disorder or of any other exclusions your plan may have regarding treatment or diagnosis. If we are alerted that you have non-parity coverage for our services, our office will notify you by mail what your actual coverage is determined to be. You may also contact your insurance company directly to find out the terms of your non-parity coverage. While we always try to help you get the best coverage for your visit, the final decision about your diagnosis is always made by your doctor. Notice of Privacy Practices You agree that you have been given a copy of Community Psychiatry s Notice of Privacy Practices, which describes the ways in which Community Psychiatry can use and disclose protected health information. You further agree that you have been given the opportunity to review and ask questions regarding the same. You understand that a copy of our Notice of Privacy Practices will be posted in the reception area of our offices and on our website. You further understand that when we amend our Notice of Privacy Practices, we will provide you with the amended version at your next scheduled visit. NOTICE TO CONSUMERS Medical doctors are licensed and regulated by the Medical Board of California (800) Page 5 of 11

6 Acknowledgement of Patient Agreement If any part of this Patient Agreement (including any attachments) is held to be unenforceable, the remainder of this Patient Agreement will remain in effect. This Patient Agreement, together with the attachments hereto, represents the entire agreement of the patient and Community Psychiatry (including all physicians and psychotherapists) with respect to the subject matter hereof. By signing below you state that you have read and agree to this Patient Agreement in its entirety. Print Patient s Name Patient s Date of Birth Signature of Patient Date Signature of Parent/Guardian or Personal Representative Date If you are signing as a personal representative of an individual, describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.): Contact Information Please indicate below the means by which you consent to Community Psychiatry contacting you: I give the staff of Community Psychiatry permission to contact me directly on my: Home phone Work Phone Cell phone Other I give the staff of Community Psychiatry permission to leave a message for me on my: Home phone Work Phone Cell phone Other I give the staff of Community Psychiatry permission to me at the following address: Page 6 of 11

7 Patient Agreement Attachment 1 Consent for Treatment I am voluntarily seeking psychotherapy and/or psychiatric treatment by the psychiatrists and/or psychotherapists at Community Psychiatry for the purpose of diagnosis and treatment, and I do hereby consent to such examinations, treatments and/or diagnostic procedures as may be deemed advisable by my treating physician or psychotherapist. I understand that there are both risks and benefits to psychotherapy and/or psychiatric treatment. I am aware that all medical care, including psychiatric care and psychotherapy, is not an exact science and I acknowledge that no guarantees have been made as to the result of such examinations, treatments and/or diagnostic procedures. I also understand that while the course of my treatment or treatment of my child is designed to be helpful, it may at times be difficult or uncomfortable. For Minor Patients: By signing below, you agree that you have legal custody and authority to consent to the child s treatment. You further agree that if you share custody of the child, all parties who have legal custody of the child have been made aware of, and consent to treatment at Community Psychiatry. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction. By signing below you state that you have read and agree to this Consent for Treatment in its entirety. Signed: Date: Print Name: If not signed by the patient, please indicate: Relationship: Parent or guardian of unemancipated minor patient Health care surrogate or conservator of an incompetent adult or emancipated minor patient Name of Patient: Page 7 of 11

8 Patient Agreement Attachment 2 Acknowledgment of Responsibility for Payment The accounting and collection systems for missed co-pays and unpaid deductibles are expensive and cumbersome for our practice. If you incur a balance that you are unable to pay in full when due, we ask that you establish a payment plan with our billing department. If you have a past due amount, and you establish and comply with such payment plan, we will still be able to see and treat you as a patient. However, if we are unable to collect on a balance owed, we may be unable to continue your treatment. If you would like to call our billing department to inquire about a balance owed, or make payment arrangements, you may contact them at (866) I hereby authorize payment of insurance benefits directly to the Community Psychiatry for payment of medical services. I understand that I am financially responsible to Community Psychiatry for all charges not covered by my insurance including (but not limited to) co-payments and deductibles, which are due at the time of my visit. I further understand that my insurance company may not cover two mental health visits on the same day. Accordingly, I understand that if I schedule a visit with my psychiatrist on the same day that I meet with my psychotherapist, I am responsible for whichever appointment is not covered. The adult accompanying a minor is responsible for full payment. This is regardless of any divorce decree (which is a contract between the parents; not between you and your doctor). If an adult other than the adult accompanying a minor is responsible for a minor's bill, the adult accompanying the minor is responsible for paying the physician fees and may collect reimbursement from the responsible adult. Parents are responsible for sending co-payments for unaccompanied minors at each visit. I have been informed of my doctor s cancellation policy and acknowledge that I am financially responsible for missed or cancelled appointments if I miss or cancel without two business days notice. I understand that insurance does not cover missed or cancelled appointments. In the event that my insurance coverage stops, I understand that it is my responsibility to notify Community Psychiatry before utilizing further services. I agree that I am financially responsible for all services that my child or I utilize after my insurance coverage ends. By signing below, you state that you have read and agree to this Acknowledgement of Responsibility for Payment in its entirety. Person Responsible for Payment Name (Please Print) Signature Date Patient s Name (Please Print) Page 8 of 11

9 PATIENT INFORMATION Disclosure Authorization (Billing and Payment Activities) NAME: ADDRESS: PERSON/ORGANIZATION PROVIDING INFORMATION NAME: Community Psychiatry ADDRESS: PERSON/ORGANIZATION TO RECEIVE INFORMATION (INSURANCE) NAME: ADDRESS: DETAILED DESCRIPTION OF INFORMATION TO BE RELEASED: Entire Medical Record (excluding psychotherapy notes, mental health records covered by CA Welfare & Institutions Code 5328, HIV/Aids Test Results and Drug/Alcohol Treatment Program Information) NOTE: Signatures Required if Any of the Following are Checked: Mental Health Records covered by CA Signature: Welfare & Institutions Code 5328 HIV/AIDS Test Results Signature: Drug/Alcohol Treatment Signature: Program Information PURPOSE(S) OF THE DISCLOSURE: The purpose of the disclosure is so that Community Psychiatry can conduct billing and payment activities. Unless sooner revoked, this authorization expires on the date that is one year from my last date of treatment by Community Psychiatry. Page 9 of 11

10 I understand: This authorization cannot be used to authorize the disclosure of information for marketing purposes or for the sale, license to use or lease of information; no remuneration shall be provided to the disclosing party in connection with this authorization. I authorize the use or disclosure of the information specified above for the purpose(s) listed above. I understand this authorization is voluntary. Treatment will not be conditioned on signing this authorization unless the purpose of my treatment is solely to create protected health information for disclosure to the party that is to receive the information pursuant to this authorization. In that event, the consequence of not signing this authorization is that treatment may not be provided. I may revoke, cancel or modify this authorization by providing written notification to the disclosing party at any time except to the extent that action has been taken in reliance on it. The authorization will stop or be modified on the date my notification is received. Unless I have specifically requested in writing that the disclosure be made in a specific format, the information may be disclosed in any manner deemed appropriate by the disclosing party and consistent with applicable law. I have a right to inspect and copy the information that is to be released. This information that has been disclosed could include information from records protected by Federal confidentiality rules (42 CFR part 2). To the extent applicable, the Federal rules prohibit the recipient from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. The organization I have authorized to receive the information may potentially further disclose the released information, which makes it no longer protected under the HIPAA Privacy Law. However, under California law, the recipient may not further disclose the information except in accordance with a valid authorization or another legally permitted purpose. The disclosing organization is not responsible for the conduct of any other entity. I understand that I have a right to receive a copy of this authorization. Page 10 of 11

11 I hereby authorize the disclosure of the information described above to the recipient listed above. Patient Name Patient Date of Birth Signature of Patient Date Signature of Parent/Guardian or Personal Representative Date **If you are signing as a personal representative of an individual, describe your authority to act for this individual (power of attorney, healthcare surrogate, etc.): Signature of Witness Attesting to Identity & Authority Date Internal Use: *Patient given copy Page 11 of 11

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