PHHC Practice Policy
Psychiatry and Holistic Health Center requires all clients to update their Consent for Services, Release of Information, and Credit Card Authorization annually to continue services.
Provided here are our most current practice policies, a copy of the Consent for Services form, some frequently asked questions about policies and the practice, and resources and educational materials for HIPAA.
Practice policies may be subject to change over time, in which a new signed Consent for Services form will be required from clients. This page will also be updated accordingly.
1
I am providing informed consent, meaning that I have thoroughly discussed the risks and benefits of treatment with my provider today and choose to continue treatment with my provider.
2
I understand that my provider has the right to prescribe or NOT prescribe any medications as my provider sees clinically appropriate.
3
I understand that if I am receiving controlled substance prescriptions, I must receive my prescriptions from my provider, in person, at least monthly, until we decide otherwise together.
4
I understand that any charges that are denied, rejected, or not covered by insurance are my financial responsibility.
5
I understand that all patients are required to keep an active credit card on file, and that patient (or guarantor) SSN is required for billing purposes only.
6
I understand that payment for services, including any co-pays/deductibles/co-insurance/self-pay, is due as soon as a balance is accrued.
7
I understand that I will owe $150.00 for any requests to reschedule, missed appointments, or cancellations with less than 48 business hours notice. I understand that I will owe this rescheduling fee out of pocket. I understand I may be terminated as a client for more than three missed appointments.
8
I understand that it is my responsibility as the patient to be aware of any deductibles, copay/coinsurance, and any other out-of-pocket expenses I may incur.
9
If applicable, I have been informed of the self-pay rates. These may be subject to change. I understand that I will be notified ahead of time before any increase in rates.
10
I have received a copy of HIPAA compliance regulations and how to access more information on HIPAA.
11
I understand that Psychiatry and Holistic Health Center will not disclose any information about me or my treatment here, or the fact that I am a patient here, without my written consent.
12
However, I understand that my protected health information (PHI) may be shared to carry out treatment, payment, and healthcare operations; and my PHI may be shared without my authorization in cases of emergency, child or elderly abuse, serious threat of self-harm or harm to others, and for certain legal matters.
13
I understand that Psychiatry and Holistic Health Center does not provide any emergency care and that I am to call 911 if I need emergency care.
14
I understand that I may be terminated as a client of Psychiatry and Holistic Health Center at any time for any reason that my provider sees as appropriate and that I may terminate my care with Psychiatry and Holistic Health Center at any time. Upon termination, I understand that I may be provided with no more than a 90-day supply of medication refills.
15
I understand that this is a teaching clinic, so there may be students, interns, and/or supervisors present during my appointments. I also understand that I may be working primarily with a student or intern, but that their supervisor may intervene as needed. I understand that these students and interns are fully supervised by independently and fully licensed senior providers.