Thank you for choosing this office and welcome.

Transcription

1 Thank you for choosing this office and welcome. My office has scheduled an initial consultation for you for a psychiatric evaluation. This initial evaluation will last approximately one and a half hours. The charge for this appointment is $ Please arrive at least 15 minutes prior to the time of your initial appointment time in order to register. Enclosed you will find several forms/measures which I requested that you fill out now, and return to me in person or via the private (which the receptionist can provide you). These measures are very important, and I will review all of them prior to your first appointment with me. I know these measures can be intimidating, or difficult or first, but they are HIGHLY insightful to me, and will be extremely helpful in guiding me to the best and most effective treatment for you. Please do your very, very best to get them back to me as soon as is humanly possible. Please bring with you: 1. All current medications, including over the counter medications; 2. Any records which you have in your possession of previous psychiatric treatment and/or evaluations; Because this office does not currently contract with any insurance carriers, you will be expected to pay in full at each visit. This office will be happy to provide you with the paperwork necessary for you to file for any out of network benefits your insurance company offers, so that your insurance company may reimburse you according to the terms of their policy. It is my policy that the first visit is always paid in full at the time of the visit. (As per office policy, only). PLEASE NOTE MY CANCELLATION POLICY. If you miss your first scheduled appointment you will be required to place $ deposit in order to reschedule appointment. Once you are an established patient, a $ fee will be charged for any missed appointments, or for any appointments cancelled less than 24 hours in advance. All cancellations must be made during office hours, Monday thru Friday, 8:00 a.m. to 5:00 p.m. Monday appointments must be cancelled by noon on the previous Friday. (PT Initial)

2 It is the policy of this office to keep a copy of an active credit card on file, with a patient signature for authorization to bill for any missed or cancelled appointments (as per policy only). (PT Initial) For training purposes, and to ensure the safety of all patients, guests and family who come here, as well as for all all staff who work here, this building property and premises is under audio/video camera surveillance. The utmost confidentiality and discretion is assured as per state and federal guidelines, via the Patient Privacy Act and HIPPA state and federal guidelines. We will provide this information to you prior to your appointment electronically (via your private patient portal link), and in writing at your first patient appointment. Every patient in treatment at this facility, and/or their guardian, must initial a statement that they have been informed of this policy, and that they are in agreement with continuing with treatment under this policy, with the full consent and knowledge that they may be audio/video taped at any time. (PT Initial) PLEASE NOTE MY CANCELLATION POLICY. Once you are an established patient, a full fee will be charged for any missed appointments, or for any appointments canceled less than 24 hours in advance. (As per office policy only, and per the individual discretion of Dr. Osborne). All cancellations must be made during office hours, Monday thru Friday, 8:00 a.m. to 5:00 p.m. Monday appointments must be cancelled by noon on the previous Friday. (PT Initial) It is the policy of this office to keep a copy of an active credit card on file, with a patient signature to authorize billing for any missed or cancelled appointments (As per Office Policy Only). (PT Initial) Patient authorizes receipt of an Office Practices Copy of Patient "Notice of Privacy Policies as well as HIPAA. This information was provided initially electronically, (via each private patient portal link) and again offered in writing at each patient s initial appointment, and is posted in writing in the Lobby of each patient waiting room, and is offered to each patient in writing at any time. (PT Initial) Three very private waiting rooms are provided: one for children and adolescents, one for adults, and one for anyone in distress or requiring the utmost of discretion. A private entrance and exit is provided, if needed. Appointments are made one at a time, and patients are not grouped together, in order to better assure their privacy.

3 Please call if you have any questions. It is the desire of the entire office staff here to deliver the highest quality care, and for you to be comfortable and satisfied that we are doing everything we can to help you. Please let us know immediately if you have any difficulties or concerns. Thank you, and again welcome. It is my pleasure, and the pleasure of my entire office staff, to serve you with honor and respect, in the safest and most comfortable environment we are able to provide. Thank you for choosing us, and allowing us the opportunity to work with you. Dr. Osborne

4 AUDIO/VIDEO CAMERA SURVEILLANCE ACKNOWLEDGMENT AND AGREEMENT I,, understand and acknowledge that I have been educated and informed that the building and property of the business of Debra Ann Osborne, M.D., L.L.C., is under audio/video camera surveillance. Audio & Video Camera Surveillance is provided at this facility for the safety and security of all patients who enter this facility and for all staff who work at this facility. Audio & Video Camera Surveillance is designed to help make all patients, family, guests and staff who enter this facility feel more safe and secure while around and on this premises. The privacy and confidentiality of all patients who come to this facility for help and treatment will be governed by the laws and privacy assured by the state and federal guidelines regarding a patients Notice of Privacy Practices, (provided, patient initials, ), as well as The Health Insurance Portability and Accountability Act (HIPAA), (provided, patient initials ). Patients may be on Audio/Video Camera Surveillance at any time while on this property or in the building of this business. The surveillance will not be accessed or reviewed unless criminal activity occurs on this property, or in the event of a criminal allegation against a patient, family member, guest or staff member is made and/or filed against a person while on this premises. Information will never be released about anyone from this facility unless strictly adhered to by state and federal guidelines, and always within adherence to the Patient Notice of Privacy Practices and HIPPA ; as well as REQUIRED to do so by federal, state, or local law. As always, it is our pleasure to work with you. We are extremely invested and committed in maintaining the safest environment humanly possible, while continuing to protect your privacy, confidentiality, and discretion at every step along the way. Thank you very much for providing us your faith, and this opportunity to serve you; we will do so with dignity and pride. Patient Signature: Date: Guardian Signature: Date: Witness: Date:

5 PAYMENT AGREEMENT WITH THE OFFICE OF DEBRA ANN OSBORNE, M.D., L.L.C It is a pleasure to have you with our office. We greatly look forward to working with you. Please understand the importance of keeping your appointments. It is nearly impossible to adequately treat a patient who does not keep their appointments. Excessively missed appointments will result in dismissal from this practice. We make every effort to be here for you as scheduled. We work very hard to be respectful of your time, and typically run on schedule. As with all medical offices, we cannot predict emergencies which may arise, and we greatly appreciate your patience during these times. In advance, we would like to make you aware that it is the policy of this office to keep an active credit card for every patient, or the appropriate patient guardian, on file, in the event of failed payments, or missed appointments. Your signature below demonstrates that we have discussed this policy, and that you are aware of it, and in agreement with it. Your signature below allows this office to bill your credit card (as per office policy only) in the event you miss a scheduled office appointment without cancelling the appointment as per office policy. I,, understand that it is the policy of this office to keep a copy of an active credit card for every active patient, or the appropriate paying patient s guardian, on file. I understand that this office is not currently not on any healthcare plan or active with any health insurance carriers. I understand that this is a Fee for Service office, and that all fees are to be paid, in full, at the time of service. I understand, that I am expected to provide 24 hours advanced notice for cancellation for all scheduled appointments by calling this office during regularly scheduled business hours. This means that I will notify this office by Friday at noon for any appointments scheduled for the following Monday. I understand that I will be charged a $ fee for any missed appointments that I do not call to cancel or to reschedule within 24 hours in advance of missing the scheduled appointment. Exceptions to this policy will be made at the discretion of Dr. Debra Ann Osborne. Patient Signature: Date:

6 Guardian Signature: Date: Witness: Date:

7 PATIENT CONSENT AGREEMENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION FOR TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS I,, understand that as part of my healthcare, Debra Ann Osborne, M.D., L.L.C., originates and maintains medical health records describing my health history, symptoms, examination, test results, laboratory results, diagnoses, previous and current treatment, and any plans for future treatment. I understand that this information serves as: A basis for planning my care and treatment A means of communication among the many health care professionals who contribute to my care A source of information for applying my diagnoses and treatment to my bill A means by which a third party payer may verify that services billed were actually provided, and A tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand that I have been provided with a Notice of Privacy Practices for Protected Health Information that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that Debra Ann Osborne, M.D., L.L.C., reserves the right to change their notice and practice and, prior to implementation, will provide a copy of any revised notice at my next scheduled appointment at my request. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, co-payment, or healthcare operations and that Debra Ann Osborne, M.D., L.L.C., is not required to agree to the restriction requests. I understand that I may revoke this consent in writing, except to the extent that Debra Ann Osborne, M.D., L.L.C., has already taken action in reliance thereon. I wish to have the following restrictions to the use or disclosure of my health information:

8 I fully understand and accept or decline the terms of this consent. Patient s Signature Date Guardian s Signature Date Witness Signature Date

9 AUTHORIZATION TO DISCLOSE INFORMATION FOR PURPOSES REQUESTED BY PATIENT OR PHYSICIAN S OFFICE I,, hereby authorize Debra Ann Osborne, M.D., L.L.C., to disclose protected healthcare information to the below mentioned healthcare providers for medical and/or mental health reasons. The information may include, but is not limited to, letters which discuss my visits(s), treatment plan, and treatment progress, and copies of office visit notes, laboratory results, diagnostic reports, treatment measures or other communications, such as phone calls - which may be deemed necessary to provide effective communication between the various healthcare providers involved in my treatment and care. This authorization shall be force and effect until (specify date or event that relates to the patient or the purpose of the use or disclosure), at which time this authorization to use or disclose this health information expires. NAME: ADDRESS: PHONE: FAX: NAME: ADDRESS: PHONE: FAX: Patient s Signature Date Guardians Signature: Date Witness: Date

10 PATIENT APPOINTMENT REMINDER CONSENT I,, hereby give my consent for the office of Debra Ann Osborne, M.D., L.L.C., to call my home, office, or text me or me for the purpose of appointment reminders in advance of my scheduled appointments. Patient preferred means of communication for appointment reminders: Patient Signature: Date: Guardian Signature: Date: Witness: Date:

11 Specializing in Child, Adolescent & Adult Psychiatry OFFICE PRICES: New Patients/Adults 60 to 90 Minutes $ New Patients/C&A 90 to 120 Minutes $ Follow-up Appointments 30 Minutes $ Follow-up Appointments 45 Minutes $ Follow-up Appointments 60 Minutes $ ***Time for phone calls and paper work gathered and provided (court, disability, and letters, etc.) will be charged. Fee is based on 15 minute units for a charge of $50.00 each unit. I understand I am expected to provide 24 hours advanced notice for cancellation for all scheduled appointments by calling this office during regularly scheduled business hours. I understand I will be charged a $ fee for no call, no show. I understand this is a fee for service office, and that all fees are to be paid, in full, at the time of service. WE ACCEPT CASH, CHECK & ALL CREDIT CARDS Dr. Osborne is not a designated provider for any healthcare plans or insurance carriers. A Super Bill may easily be generated for you, should you desire to bill your insurance company personally for an out of network provider. Your utmost discretion and confidentiality is always assured. It is our pleasure to serve you.

12 Patient Signature: Date: Guardian Signature: Date: Witness: Date: