Consent for Treatment

Understanding Psychiatric Services and Consent to Treatment

The success of psychiatric services depends upon a high degree of trust between you and your provider. This document has been prepared to inform you about what to expect from psychiatric services and from your provider, as well as office policies, procedures, and practices. Please read it carefully and thoroughly. You are encouraged to ask any questions that may arise and obtain a copy of this document for your records. You can revoke your consent to treatment in writing at any time.

Confidentiality and Privacy Policy

We understand that your personal health information is very sensitive and your privacy will be respected during treatment. The content of all discussions and the information you disclose to your provider is considered confidential and will generally not be released without an Authorization for Release of Health Information form. Some exceptions to confidentiality are the following situations in which your provider may choose to, or be required to, disclose personal health information:

• If you provide written consent to have the information released to another party

• In the case of your death or disability information may be disclosed to your Executor

• If you waive confidentiality by bringing legal action against your provider

• In response to a valid subpoena from a court or from the secretary of the State Department of Health for records related to a complaint, report, or investigation

• If your provider reasonably believes that disclosure of confidential information will avoid or minimize an imminent danger to your health or safety or the health or safety of another

• If without prior written agreement, no payment for services has been received after 90 days, the account name and amount may be submitted to a collection agency

• Limited data in compliance with mandated Public Health Disclosures

• With any other legal duty, obligation, or right to report

Your provider is a mandated reporter and required by law to disclose certain confidential information that pertains to suspected abuse or neglect of children, suspected abuse or neglect of vulnerable adults, or as otherwise required in proceedings under Missouri law.

Treatment Approach

There is no such thing as a “one size fits all” model of care, especially for psychiatric services. Psychiatric services at The Source Behavioral Health are integrative, meaning that all aspects of your health are considered when providing care. Your first meeting comprises a thorough medical and psychological history. Your provider works collaboratively with you and your care team to determine the treatment option that is best for you.

Treatment options include thoughtful and respectful medication management when appropriate, as well as information related to nutrition, sleep, and pain management strategies. Your provider will offer psychological support as well as psychological education. You may experience uncomfortable feelings and difficult or troubling emotions may arise. Your provider cannot make any guarantees regarding specific outcomes or results of the treatments provided. You have the right to choose the type of treatment recommended by your provider, including no treatment at all. Your provider will determine if the level of care he/she is able to provide is adequate and sufficient to meet your needs. When needed, your provider will offer referrals to other qualified professionals or to a higher level of care such as an Intensive Outpatient Program (IOP) or hospitalization in the case of serious risk to yourself or others.

Medications

If therapeutically appropriate, your provider may prescribe medication as part of your treatment. As with any treatment protocol, psychiatric medications may cause side effects. Your provider will discuss the specific known side effects and possible benefits of any medication that may be indicated. Every individual is unique and responds differently to medications. If you begin to experience anything you believe may be a side effect or interaction, even if you don't recall it being discussed during your appointment you should notify your provider immediately. If you are requesting refills of non-controlled substances, you should call your pharmacy directly. If you are requesting a refill of a controlled substance, your provider must see you in person no less than once every three months. For the most expedient response, you are encouraged to email your provider. Please refer to the Electronic Communications section of this document for additional information about your privacy when communicating via email. However, your provider may not be able to respond immediately. Please allow 72 hours for a response from your provider. Please note that not all medications are covered by insurance. Or, your insurance plan may change which could affect your coverage of certain medications. If you need an alternative medication prescribed, please contact the provider as directed above.

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It is your responsibility to keep track of the amount of medication and the total number of refills you have remaining so that you do not unexpectedly run out of medication. It is also your responsibility to ensure that your medication is maintained in a secure manner to avoid theft or inadvertent ingestion by a third party. Any request for replacement of medication due to destruction, theft, or other loss, will be predicated on planning to prevent such future losses. In order to best assess potential adverse impacts on your health including, but not limited to, medication interactions, you must inform your provider whenever another provider prescribes you a new medication or another therapeutic agent. It can be very harmful to discontinue or alter the dosing of your medication without the guidance of a qualified healthcare provider. If you feel that your current medication and/or dosage is not appropriate, let your provider know.

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Electronic communications

For your convenience, statements, superbill receipts, appointment reminders, and private messages from your provider may be sent to you through our practice software. Such information can be accessed by a password that is only known to you. If you forget your password and need to access your private health information, please contact our office. Communications transmitted electronically through the EHR are compliant with the Health Information and Accountability Act (HIPAA) and are thus secure. You may also receive electronic communications from your provider such as E-mail that is not secure. Email can be relatively easily accessed by unauthorized people and can compromise your privacy and confidentiality. A non-encrypted e-mail, such as your provider's email, is even more vulnerable to unauthorized access. Although your provider's emails are not encrypted, privacy measures are taken such as firewalls on your provider's computer as well as virus protection and the use of a password. Please do not use SMS (mobile phone text messaging) to contact your provider. Engaging in this way can compromise your confidentiality.

Phone contacts between appointments can be helpful for discussing particular events or situations that are causing you distress. If phone contact becomes routine and/or a phone conversation becomes lengthy, you may be charged. Note that not all insurance companies reimburse for phone sessions. If this is the case, you will be responsible for the full session amount. E-mail and phone communications are helpful tools for asking general questions of your provider, confirming appointments, and conveying relevant information and updates. However, e-mail and out-of-session phone contact should not be used as a substitute for psychiatric services. Your provider will not provide treatment via email. Please notify your provider if you decide to avoid or limit, in any way, the use of secure messaging or Email. Otherwise, your provider may communicate with you via secure messaging or E-mail when necessary or appropriate. If you communicate confidential or highly private information via E-mail, your provider will assume that you have made an informed decision and will honor your desire to communicate via email. Please do not use e-mail for emergencies. Please, note that all electronic communications are part of your clinical record.

Social Media Policy

At psychiatryhelps.com we make your privacy our priority. Your provider's policies regarding conduct on social media platforms are to ensure a professional relationship and protect your privacy. The nature of the confidential relationship between you and your provider is known to contribute to the effectiveness of treatment.

Friending and following

Your provider will not accept friend or contact requests from current or former clients on any social networking site such as Facebook or LinkedIn. psychiatryhelps.com maintains accounts on select social media platforms. These accounts are not managed by any individual provider. Rather, these accounts are associated with the practice and allow public access to blog posts and relevant news and community resources. Clients are encouraged to view the psychiatryhelps.com Facebook, Twitter, or LinkedIn page and read or share articles posted there. The psychiatryhelps.com Twitter account only follows other mental health professionals as well as state and local organizations. There is no expectation for clients to follow any social media account. You should be able to subscribe to social media accounts via RSS without becoming a fan and without creating a visible, public link to this page.

Please do not attempt to contact your provider or the psychiatryhelps.com office via social networking sites. This could compromise your confidentiality and you will not receive a response as these sites are not monitored regularly.

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Online reviews

We understand that there are more choices than ever when it comes to choosing the right provider. With the Internet impacting virtually all aspects of our lives, it has been increasingly more common for consumers to find and vet businesses online. In the case of psychiatric services, online business review sites such as Yelp pose a unique challenge for both the provider and client. The Source Behavioral Health or your provider may be listed on one or more of these sites. If you should find a listing, please know that this is not a request for a testimonial, rating, or endorsement from you. It is unethical for your provider to solicit a testimonial from a current or former client. If you post an online review based on your experience receiving psychiatric services, you are publicly acknowledging a provider-client relationship and have thus waived your right to privacy. You should be aware of any potential negative impact that could occur on the basis of this disclosure such as the possibility of this exchange becoming a part of your legal medical record. Your provider cannot respond to any review on a business review site for confidentiality reasons. Thus, you are encouraged to share your comments - either positive or negative, directly with your provider. Your provider is always willing to discuss your reactions and work with you to make your experience in treatment a positive one. Social networking & internet searches.

It is not part of your providers' regular practice to search for clients via Google or other social media platforms. Extremely rare exceptions may be made during times of crisis. If your provider ever resorts to such means, this will be fully documented and discussed with you at your next appointment.

Emergencies

psychiatryhelps.com office and your provider do not offer emergency services. Your provider can be reached during business hours. If you are in need of emergency assistance, call ‘911' or the National Suicide Prevention Lifeline at 1-800-273-8255. Unless otherwise specified, phone messages will be returned by your provider within 24 hours.

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Fees

Insurance reimbursement

Claims (mental health invoices) may be submitted to your insurance company on your behalf for services rendered. You may be responsible for a co-payment amount or deductible amount. This amount varies depending on the type of policy that you carry with your insurance company. In such cases, co-payment or deductible fees are due at the time of your session. We accept debit and credit cards, cash, or check payable to ‘The Source Behavioral Health'. Not all issues, conditions, or problems are reimbursed by insurance companies. Although we do our best to verify your eligibility for mental health services, psychiatryhelps.com is not responsible for denied claims. In the event that a claim is denied, you are personally responsible for the full amount due. It is your responsibility to understand your mental health services coverage with your insurance. You are advised to seek assistance in understanding your mental health benefits by contacting the Human Resources Department with your employer or by calling the ‘Member Services' number on the back of your card.

Changes in your insurance plan or coverage

Changes in your insurance company or insurance coverage (such as annual renewal, expiration, or type of coverage provided) may affect your financial responsibility. Please notify your provider if you change your insurance plan or anticipate a change in your coverage.

Fee for service arrangements

If you are not using insurance, or if a claim has been denied, Psychiatric Service Fees at psychiatryhelps.com can be made by debit or credit card, cash, or check payable to ‘Midwest Psychiatric Associates LLC'. As the administrative costs of running a practice change, session fees may be adjusted accordingly. In such cases, your provider will discuss the adjusted fee with you at least 30 days before a change will come into effect.

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Credit card on file

Your provider will collect fees at the time of service. If you use a credit card, your credit card will be saved on file through our secure practice software. You will have the option at the time of the session to pay via your credit card on file. Please inform your provider if you do not want your credit card on file to be processed in this manner. Refer to the Electronic Communications section of this document for privacy information.

Client statements

At the end of each month, clients with outstanding balances will be sent an Account Statement. This statement will include any balances owed, and a summary of services received. As mentioned previously, payments are due at the time of the session. However, if a statement is received, payment for the balance due is expected within 15 days of the date posted on the client statement. You may also pay in advance for your treatment sessions either by credit card, check, or cash, and your provider will deduct services rendered from your total credit. Returned checks In the event that a deposited check is returned due to insufficient funds (“bounced” checks), a $50.00 fee will be charged. In addition, you will be responsible for the original amount owed. If such situations arise, you may be asked to pay either with a credit card or cash for subsequent sessions.

Missed appointments and late cancellations

Your appointment is reserved exclusively for you. If you miss your appointment or cancel at the last minute, your provider is unable to care for another client. Thus, missed appointments or those canceled within 48 hours of scheduled appointment time are subject to a missed appointment fee equal to the allowed amount authorized by your insurance, or the full session amount if you have a fee-for-service arrangement.

Superbills

Superbills are specialized statements that include the type of service provided, the date services were rendered, and a formal diagnosis. These statements are prepared upon request and provided on a monthly basis. You have the option to submit Superbill statements to your insurance company for possible partial reimbursement.

Other Office Policies

Scheduling appointments

Appointments will be made using the convenient and easy online booking portal This system allows you to access your provider's personal calendar as well as receive reminder emails. You are encouraged to schedule your appointments online for ease of convenience and to reserve your preferred appointment day and time. Refer to the Electronic Communications section of this document for privacy information.

Animals in the office

In order to ensure the comfort and safety of our clients and staff, we ask that you refrain from bringing any animals or pets into The Source Behavioral Health common and office areas. This will allow us to provide a more comfortable space for clients. Thank you for your understanding. psychiatryhelps.com adheres to the requirements set forth by the U.S. Department of Justice and the Americans with Disabilities Act (ADA) for the allowance of Certified Service Animals. For those clients who currently have a Certified Service Animal, we ask that you speak with your provider individually to discuss your treatment goals and determine whether it would be clinically appropriate and beneficial to bring your Service Animal to your session.

Arriving on time for your appointment

Please make every effort to arrive on time for your appointment. If you arrive early, you are welcome to wait in our comfortable waiting area and relax before your meeting. You will benefit the most from participating in a full session. We understand that some things are out of your control such as traffic. In the case that you know you will be late for your appointment, please call ahead. If you are more than twenty minutes late your provider may decide that it is not in your best interest to hold the session. In such cases, you may incur a missed session fee. If arriving late to your appointments becomes a pattern and it interferes with your treatment plan, you and your provider can discuss alternative solutions such as meeting at another time or location or receiving care from another provider.

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Conclusion of treatment

There are many different levels of care that providers provide. Although psychiatric treatment is a very helpful tool for many people, the level of care offered at psychiatryhelps.com may sometimes not be the best match to a client's needs. In addition, your provider may not be fully prepared to manage certain concerns that are outside of his or her scope of competence. In such cases, alternative care with a clinician offering specialty care may be necessary. If at any point during treatment your provider assesses that he or she is not effective in helping you reach your therapeutic goals, you will be given a number of referrals that may be of help to you. With your request and written permission, your provider is available to consult with your new provider in order to help with the transition. If you are no longer able to receive treatment due to financial concerns, your provider will work with you to establish a payment plan, or offer personal referrals to help you establish care with another qualified professional who offers services at a lower fee.

In the event that your provider is suddenly unable to continue to provide professional services or maintain client records due to incapacitation or death, he or she has designated a trusted professional colleague to be his or her professional executor. Your provider's professional executor will be given access to your file and may contact you directly if such a circumstance should occur. Your provider's professional executor may offer to meet with you to help cope with the transition or assist you in accessing care with another qualified mental health professional.

Please sign below to indicate that you understand and agree to the above, and consent to treatment.