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NEW PT TREATMENT AND CONSENT FORMS

PATIENT REGISTRATION

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Nature of the Therapeutic Relationship:

Your plan of care may involve supportive psychotherapy and/or medication management. This requires an active engagement on your part to talk about your life openly and honestly and take the medications as prescribed. If difficulties arise, I hope that we can work together to resolve them as quickly as possible. Your relationship with your provider is a professional and therapeutic relationship. To preserve this therapeutic relationship, the provider will not have any other type of relationship with you. Personal and/or business relationships undermine the effectiveness of the therapeutic relationship. Medications: Your provider will explain important side effects of any medication prescribed for you. If you encounter an unexpected side effect from the medication, please call the office immediately to discuss a dosage adjustment and to request an emergency visit. Please check your medication supply before your scheduled visit, so that we can prevent you from running out of your medications. Your medication will only be refilled once in a 90-day period and you will be required to schedule an appointment to see your provider. Your provider will only refill enough medications to cover you until your next appointment date. All medication adjustments and refills are done during your appointment time. This practice does not refill or adjust medications by phone, fax, or email. All stolen non-controlled or controlled prescriptions require a police report. Controlled medications are monitored carefully. Sharing, distributing, or alterations of these prescriptions are in violation of the law. You must follow up for refills, no exceptions. Please see detailed prescription refill policy regarding controlled substances. Please be advised that drinking alcohol while taking psychiatric medications can lead to negative outcomes.

Appointments:

If you are not able to keep your appointment, you must notify the office at least 48 hours in advance for all follow up appointments and 72 hours in advance for all new patient appointments at (832) 879-2107 or login to your Patient Ally account to cancel and/or reschedule your appointment. If you are a NO SHOW, you will be charged the appropriate fee for a No Call/No Show. If you leave before being seen, this will be considered a NO SHOW. For new patients a fee of $150.00 will be charged if you NO SHOW, and existing patients the fee is $75.00. If you have missed more than two consecutive appointments or have consistent no shows, we reserve the right to discharge you from psychiatric services and refer you to a different provider within the community. If you miss a Saturday appointment, you will be charged the appropriate no show fee and will not be rescheduled for any future Saturday appointments as this is a convenience day and we expect for you to be present. If you cancel and reschedule your appointment 2 days in advance of your regularly scheduled appointment, then you are not charged a late cancellation fee. Insurance does not reimburse late cancellations or no show/no call fees. Late Arrivals: If you are more than 15 minutes late for your appointment, you will be rescheduled. We understand that things arise and that may require you to be late, however, we cannot expect other patients to wait that have arrived on time for their appointment. All clients under the age of 18 must be accompanied by an adult. If you are not the parent or legal guardian, then there must be a release of information on file that has authorized an adult to be present during the visit as children and adolescents cannot make informed decisions.

Notice of Privacy and Confidentiality:

Privacy and confidentiality is a cornerstone of psychiatric treatment. Discussions between the provider and the client are confidential. No information will be released without your written consent, unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following situations: child abuse; abuse of the elderly or disabled; abuse of patients in mental health facilities; sexual exploitation; criminal prosecutions; child custody cases; suits in which the mental health of a party is an issue; fee disputes between the provider and the client; a negligence suit brought by the client against the provider; or the filing of a complaint with the state licensing board or other regulatory body. If you have any questions about confidentiality, you should bring them to my attention so that we can discuss the matter further. By signing this information and consent form, you are giving your consent to your provider to share confidential information with all persons mandated by law and with the agency that referred you and the managed care company and/or insurance carrier responsible for providing your mental health care services and payment for those services, and you are also releasing and holding your provider harmless from any departure from the right of confidentiality that may result

Uses and Disclosures of Information:

Uses and Disclosures of Information: Under federal law, the provider is permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. However, the state law may require me to obtain you express consent before the practice makes certain disclosures of your personal health information. Other Uses and Disclosures: This practice may also use and disclose your personal information without authorization for the following situations: Abuse, Neglect, or Domestic Violence: As required and permitted by law, this provider may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is needed, the provider will use his or her professional judgment in deciding to make such a report. If feasible, the provider will notify you promptly of any such disclosure being made. Minor: If you are a parent, legal guardian, or legal representative of a minor receiving treatment, by law the provider must disclose protected health information, to, make medical decisions on the minor?s behalf for their health care.

Confidentiality and Third-Party Payers:

Confidentiality and Third-Party Payers: You should realize that any information given at your request to an insurance company or managed care company is thereafter beyond my control. Health insurance companies sometimes give information to the medical information bureau, which may affect your future eligibility for life, disability, or other insurance. Some employers obtain identifiable data from administrators of their health insurance. Medicare and other insurance plans have the right to inspect the medical records of subscribers who file claims. In our experience, such events are rare, and we would resist them to the greatest extent legally possible, but it is important that you know that this can happen if you choose to file claims for insurance or Medicare payments. However, the best safeguard for your privacy is not to involve third parties in your treatment. Other breaches of privacy could occur in extreme situations that are beyond my control and are required by law or are essential to prevent imminent serious harm.

Duty to Warn (DO NOT SKIP THIS SECTION)

If your provider reasonably believes that you are a danger, physically or emotionally to yourself or to another person, he or she will warn the person in danger and CONTACT THE FOLLOWING PERSONS, in addition to medical and law enforcement personnel. By signing this consent form, you give your consent to make these contacts in these circumstances.

Telephone Contact Policy:

Routine calls regarding updates to your profile, office policies and procedures, medication questions, are at no charge. Calls related to a therapeutic nature and/or non-therapeutic matters, will be charged $25.00 per 10-minute increment. All calls will be returned during normal business hours. Text/Email Contact Policy: This practice does not use texting as a primary form of discussion of ongoing matters. This can be concerning to confidentiality and maintaining an optimal standard of care. If it is a non-urgent matter, please bring the topic to your next scheduled appointment. For urgent matters or if it is a medical or psychiatric emergency, please do not text or email. Please hang up and dial 911 or go to your nearest emergency room. If you have questions or concerns, please contact the office and leave a message during business hours or if after hours please leave a voicemail. We welcome non-urgent emails to communicate effectively. Please note that the confidentiality of your email cannot be guaranteed.

Tele-psychiatry Policy:

Tele-psychiatry delivers comprehensive mental health services using interactive video conferencing platforms that are HIPAA compliant. Tele-psychiatry also reduces traveling to the office, taking time off from work and/or school. Potential risks may include but may not be limited to: insufficient transmission of information due to poor video resolutions; delays in receiving mental health evaluation and treatment due to equipment or technology malfunction; security protocols may fail which may lead to a breach of privacy; and a lack of access to pertinent details that are available in a face-to-face in-person visit. This may result in errors in judgement. Your Rights: I understand that the laws that protect the privacy and confidentiality of my health information also apply to tele-psychiatry services. I understand that the video-conferencing platform is known to incorporate network and software security protocols to protect the confidentiality of information and audio/visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional breach of my protected health information (PHI). I have the right to withdraw my consent to the use of tele-psychiatry at any time and make an in-person visit to see my provider. I understand that my provider has the right to withhold or withdraw consent for the use of telepsychiatry at any time if an in-person visit is necessary to stabilize my condition. I understand that all rules and regulations which apply to the practice of medicine in the State of Texas also apply to tele-psychiatry. Your Responsibilities: I will not record any tele-psychiatry sessions without prior written consent of the provider, and I understand that the provider will not record tele-psychiatry sessions without my consent as well. I will inform the provider if any other person can hear or see any part of our session before the session begins. Equally, the provider will inform me if any other person can hear or see any part of the session before the session begins. I understand that I must be a resident of Texas to be eligible for tele-psychiatry services. I understand that my Initial Consultation must be done in-person and I must be stable on my current medication regimen prior to subsequent tele-psychiatry visits. I understand that I must see my provider in-person on a bi-annual basis. I understand that I must have a blood pressure cuff and scale to facilitate my tele-psychiatry visit. I understand that I must have a valid email address to facilitate my tele-psychiatry visit. I understand that I must follow the prompts from my UPDOX text or email sent by my provider to ensure that I can connect with my provider to facilitate my visit. Your initials indicate that you have read and understand the information provided above regarding tele-psychiatry, and that you authorize your provider to use tele-psychiatry to diagnose and treat your mental health condition.

Legal Proceedings/Court-Related Services:

We DO NOT provide or perform evaluations for custody, visitation or other forensic matters. Therefore, it is understood and agreed upon that we cannot and will not provide any testimony or reports regarding issues of custody, visitation or fitness of a parent in any legal matter or administrative proceedings. You should hire a different mental health professional for any evaluations or testimony you require. This position is based on the following reasons: (1) My statements will be seen as biased in your favor because we have a provider /client relationship. (2) The testimony might affect our therapeutic relationship and I must put this relationship first, thereby protecting the safety and confidentiality of your mental health treatment, and (3) There are other mental health professionals who specialize in court-related cases. I hereby waive my right to request court appearances or any type of legal proceedings.

After-Hours On-Call Provider Policy:

The purpose of this policy is to provide 24-hour emergency contact to clients of the practice that are in a crisis or having adverse medication reactions. If you are in a crisis or have an emergency that requires immediate attention that requires the police or fire department, please dial 911 or go to your nearest emergency room. Please do not leave messages regarding any medication refills or appointment changes as those messages will not be returned. You will need to call during our normal business hours Monday ? Friday 8:00AM to 5:00PM to schedule a medication refill appointment. Our services start at 5pm and end at 8am Monday to Friday. Weekend and holiday coverage is limited. Please try to contact us during normal business hours, if you are having medication side effects or if you are in a crisis. We are usually able to schedule you an emergency appointment to be seen and evaluated the same day, if necessary. If a client requires hospitalization, please proceed to the nearest emergency room. I have reviewed and understand the After Hours On-Call Policy in its entirety and understand the procedure for calling after hours for an emergency, crisis, or adverse medication reactions.

Prescription Refill Policy

To clarify our therapeutic relationship with our clients who are prescribed medications, we have created a policy for how we handle medication refills. If you have no-showed, cancelled, and/or rescheduled your appointment, we will not refill your medications. So, it is imperative that you keep your medication refill appointments to prevent yourself from running out of medications. We reserve the right to refuse any refill requests. Clients should contact our office directly to schedule an appointment to get a medication refill. Please check your medications prior to your next appointment to identify which ones need refilling. As a client, it is your responsibility to schedule your refill appointment in a timely manner so that you do not run out of medications. Attending office visits with the provider is required for all clients taking prescription medications. The interval will be based on your needs and the prescribed medications.

Controlled Substances

Controlled substances will not be refilled without an appointment. You must take the medication as per the provider?s instructions. This office does not issue early refills. If you miss your appointment, you will not get a refill as controlled substance refills require an appointment. If you are receiving similar medications from a different provider, sharing your medications, or taking medications from non-prescribers, you will no longer be able to receive any controlled medications from the clinic. If you alter the dosage of the prescription, you will be immediately referred out of this practice. If you are prescribed a stimulant (Schedule II Drug), you must make an appointment to receive a medication refill. There is a fee associated with refilling any medication. Please be advised that these prescriptions expire in 21 days of the earliest fill date. Prescriptions are sent electronically to your pharmacy of choice. If your pharmacy does not have the proper quantity to fill your prescription, then you must contact the office with a secondary pharmacy to resend the prescription. Please allow up to 72 hours to resend the prescription electronically. All clients taking controlled substances are required to submit a urine drug screen on initiation of any controlled substance and every quarter thereafter.

Please be advised that we do not refill medications over the phone or via email. You must have a regularly scheduled visit in order to receive the proper medication refills. If you lose your prescription, you must have a police report. We reserve the right to refuse any refill. If you are on a controlled substance, you can only refill 30 days from the date that you last filled your medication. We will not authorize any early refills. If you need medication adjustments, you must schedule an appointment. We understand that things come up and you may need to reschedule your appointment. Please contact us immediately as we offer several ways to facilitate your visit. If you are having a severe medication reaction, please proceed to the nearest emergency room or call 911. We are usually able to see you for an emergency visit the same day during our normal business hours to make medication adjustments. You can also login to the patient portal to message your provider directly.

Refill Request Fee Scale

Medication Refill for ONE Prescription Refill: $15.00

Medication Refill for TWO Prescription Refill: $25.00

Medication Refill for THREE Prescription Refills: $30.00

Regular Refill Requests (7-day supply only!): $15.00

Urine Drug Screen (Mandatory): $15.00

PRESCRIPTION REFILL DISCLAIMER

****DO NOT PAY FOR REFILL UNLESS YOU AGREE WITH THE FOLLOWING TERMS AND CONDITIONS**** 1) Quantity authorized is dependent on what is allowed within a 30-day period, according to patient's individual treatment plan, office policies, federal, state, laws, rules, and regulations. In order to receive a refill, the patient must be in compliance with their treatment plan and follow-up appointments, as determined by your provider. If an appointment is needed before the refill is given, you will be notified via patient portal. a. NO REFUNDS will be given. If there is an error, payment will be saved as a "credit" to the patient's account for future copays. b. When submitting a refill request, please indicate the following dose in the comments prior to submitting payment: Medication's name, Dosage, Last Fill Date, Preferred pharmacy (if different than what is on your individual file) MEDICATION WILL BE SENT TO THE CURRENT PHARMACY WE HAVE ON FILE, UNLESS PHARMACY IS OUT OF STOCK. 2) Refills received after 12-noon will be addressed the next business day. 3) Refills will not be honored on recognized holidays and/or when the center is closed.

Paperwork Policy

We realize that patients may need to have forms completed for disability or work. We have developed a paperwork policy to assist our clients with getting their paperwork completed in a timely manner. If you have forms that need to be completed, you must schedule an appointment with your provider to get the paperwork completed. Please read, initial, and sign below to acknowledge our paperwork policy. FMLA Paperwork: 1. You will need to sign a release of information 2. Make an appointment for completing you FMLA paperwork 3. Please allow up to 7-10 business days to complete the paperwork Social Security/Disability/Attorney Paperwork: 1. You will need to sign a release of information 2. Make an appointment for completing any social security or disability paperwork 3. Please allow up to 15 business days to complete the paperwork Formal Letters/504 Letter for School/Emotional Support Pet Letter: 1. You will need to sign a release of information 2. Make an appointment to complete formal letters/504 letters 3. Please allow up to 7-10 business days to complete the letter VA Paperwork: 1. You will need to sign a release of information to the VA with the fax number to your VA counselor 2. Make an appointment to complete any VA paperwork 3. Please allow up to 20 business days to complete any VA paperwork

Paperwork Fee Scale:

Diagnosis and/or Treatment Physician Letter: $25.00

Authorization letter to administer medication by a school nurse: $25.00

Educational 504 Accommodations Letter/Emotional Support Pet Letter: $25.00

Medical Record Processing Fee (20-pages or less): $25.00

Medical Record Processing Fee (More than 20-pages): $75.00

FMLA: $50.00

Short/Long Term Disability: $75.00

VA Disability Paperwork: $75.00

Terms of Payment

Financial Policy and Fees: Payments of all copays, deductibles, balances, and/or coinsurance are due at the time of service. We accept most insurances. If we are not on a specific insurance panel and considered out of network, you will be financially responsible for the visit. Payment is due at the time of service. We accept any major credit cards. We are more than happy to provide you with a Superbill to submit to your insurance company for reimbursement. Please notify us if you need to change your method of payment. If you leave before being seen by the provider, you will not receive a refund. This will be considered a NO SHOW. No refunds are given after a service has been rendered or per appointment policy. Fees may be re-evaluated periodically and may increase over time. We will ensure that you are notified of any fee changes prior to your next appointment. If you have a balance, you are responsible for your share of the fees once your insurance has paid. Balances are due prior to rendering services. As a service to you, our office will bill your insurance company. Being a participating provider with most insurance companies, they require that we collect these fees, as they are the terms of your health care contract. Any balances that are not covered by your insurance are ultimately your responsibility. For your convenience, we accept credit cards including Visa, MasterCard, Discover, and Debit Cards. Due to the constant changes in health insurance it is your responsibility to know your health coverage. If you should have any questions regarding your mental health coverage, it is to your advantage to call your insurance company and find out exactly what your contract covers. Their customer service representatives will be happy to assist you.

Consent to Treatment

I voluntarily agree to receive mental health evaluation, medication management, psychotherapy, psychiatric care, treatment, and/or other services and authorize the undersigned provider to provide such care, treatment, or services as they are considered necessary and advisable. I understand and agree that I will actively participate in my plan of care, treatment, or services provided. I am aware that I can be discharged at any time, if I am not adherent to the plan of care or have missed more than 2 consecutive appointments or 3 appointments in one year. By signing this treatment information and consent form, I the undersigned client, acknowledge that I have read and understood all the terms and information contained herein. Ample opportunity has been offered to me to ask questions and seek clarification of anything unclear to me. Initial Treatment Plan: By signing and initialing the policies and procedures in this information and consent form, I agree to the initial treatment plan and understand all policies and procedures of the clinic. I also understand that I must communicate any questions or concerns about my treatment plan. I understand all the policies and procedures and I have the right to revoke my consent or refusal to any treatment. Questions, Concerns and/or Complaints: If you have any questions, concerns, and/or complaints about the nature of your treatment or about your billing statement, please ask or talk to us about it. We will do our best to answer your questions promptly, address your concerns openly, respond respectfully, and take your criticism seriously. I have read and agree with the Prescription Refill Policy and understand that I am required to submit a urine drug screen and must request a refill 7 days in advance. I have read and agree with the Terms of Payment and understand that I am responsible for any and all outstanding fees, co-payments, deductibles, and/or co-insurance that is not covered by my insurance. I have read and agree with the office policy and procedures for paperwork. I have initialed the bottom of each page to acknowledge that I have read this document in its entirety.

Patient/Guardian/Parent Signature:

By inputting your FULL NAME, you are consenting that all information entered above is true and correct, and that you agree to the terms/conditions of establishing a therapeutic relationship with Gero-Psychiatric Behavioral & Mental Health Consultants LLC DBA Tranquility Behavioral Health LLC outlined above.

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