Terms of Service
Please also review Privacy Practices.
PRACTICE SERVICE AGREEMENT
Welcome to Rainwater Psychiatry. Your agreement to the following terms and conditions is required for you to receive professional services from this practice. If you do not agree, we will be glad to give you referrals to other providers.
CRISIS SUPPORT AGREEMENT
A requirement for receiving services at Rainwater Psychiatry is to complete the “Crisis Support” section located in the appointment check-in form (only exception to this requirement may be made for patients with no mood, anxiety, or psychotic disorder diagnosis). This support plan requires each patient to document strategies that are geared towards preventing the need for referral to a higher level of psychiatric care (e.g. hospitalization) if and when a crisis emerges. Secondly, each patient is required to indicate the preferred referral location and emergency contact person if a crisis is unable to be mitigated using less drastic measures.
These requirements have been drafted using the SAMHSA guidelines referenced at the bottom of this agreement and are especially founded upon the “Essential Values” (p 5) and “Principles” (p 7) described in this reference, including the avoidance of harm and person-centered interventions that account for the individual patient’s preferences and support the highest level of autonomy and sense of control.
CLINICAL SERVICES
You consent for yourself/your child to receive a comprehensive diagnostic assessment. At the end of the evaluation, we will mutually decide if we will continue treatment together.
If there is a potential of any physical danger to you or others, you will call 911 immediately or go to the closest emergency room. Rainwater Psychiatry has no reception staff to answer phone calls and your provider is NOT available for emergency or crisis situations. To reach your outside of standard business hours, use the messages section in your patient portal. This assures you health and identifying information stays protected.
I do not have admitting privileges, nor am I affiliated with or on staff at any hospital. Should I deem more intensive services are needed than I can provide, I will do my best to ensure safety and obtain the appropriate level of care, but I cannot provide that care directly and cannot guarantee the receipt or quality of care that others provide.
All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. You are entitled to receive a copy of these records unless I believe that seeing them would be emotionally damaging. If this is the case, I will be happy to provide the records to an appropriate mental health professional of your choice or to prepare an appropriate summary instead. Because client records are professional documents, they can be misinterpreted and can be upsetting. If you wish to see the records, it is best to review them with me so that we can discuss their content.
The services I provide are generally referred to as medication management. Appointments often involve some form of psycho-education and/or counseling, but I do not specifically provide psychotherapy at this practice. If it is part of our treatment plan, I will try my best to offer you referral recommendations to other local therapists and/or communicate with your therapist if necessary (only after receiving your written permission to do so).
You/your child agree to attend follow-up appointments (virtual or in-person) at your provider’s recommended interval depending upon type of medication used, severity of symptoms/risks, or other reason for which the provider can clearly explain the need.
COMMUNICATION
You will be contacted via text message and/or email for appointment reminders and via email or phone for discussing any clinical information. You can ask us to contact you in a specific way.
MEDICATION REFILLS for NON-CONTROLLED MEDICATIONS
Generally, your need for refills and your follow-up appointments should coincide:
Example - We changed the dose of your medication and gave a 1-month prescription with the plan to have another appointment the following month before deciding to continue at this dose (one reason this is important is because your insurance might require your next fill to be a 90-day)
Example - You've been maintained on the same medication(s) and were provided a couple refills on your last prescription, so you schedule your next appointment for within 3 months / prior to running out of your refills.
If you miss your appointment, forget to schedule in time, or your refills aren't correct, please reach out and ask for a refill before you run out.
MEDICATION REFILLS for CONTROLLED MEDICATIONS
These medications take extra steps and have different regulations for refills and tracking, so it is pertinent to have an appointment scheduled at least a couple or more days prior to needing a refill to ensure safe prescribing and a extra time in case of hangups at the pharmacy.
All requests for controlled medication refills outside of your appointment will only be granted in rare circumstances. Otherwise, please plan ahead to receive these refills during your appointments.
MEDICATION HISTORY
You agree to this Practice’s utilization of its electronic health record’s (i.e. Drchrono) medication history database (i.e. Surescripts) to view any recent electronic prescription(s) you have received from any provider that is being tracked in this system.
SOCIAL/ BUSINESS NETWORKING SITES
Your provider will not accept ‘friend’ or contact requests on any social networking site. Adding patients as friends or contacts can compromise your confidentiality and our privacy.
GROUNDS FOR TERMINATION
Your relationship with your doctor is at your discretion. You have the right to seek mental health treatment from any provider with whom you feel comfortable. If you have concerns about the quality or nature of the services provided, concerns about our staff, building, or billing procedures, please let your provider know. We reserve the right to terminate therapy services if anyone behaves inappropriately towards a doctor or office staff, if there is consistent failure to attend scheduled appointments, if there is failure to complete payment for services, or if either parent does not consent for services for a child.
CONFIDENTIALITY *refer to Notice of Privacy Practices
There is no guarantee of confidentiality under the following conditions:
If your provider suspects you/your child are in imminent danger of harm to self or others, or a child or elderly person is being abused or neglected (as your provider is a mandated reporter)
If a court orders a release of information
If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
If your insurance company requests to review your/your child’s case
If you pay by credit card, your provider’s name will appear on your credit card statement
If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collections agency or other responsible party
Your protected health information (PHI) may also be shared between your provider and Rainwater Psychiatry’s administrative staff or your other practitioners with whom your provider consults. Your provider may also seek professional consultation for complex cases, in which case every effort to protect any PHI that is not pertinent to the consultation will be made.
TELEPSYCHIATRY SERVICES *refer to Telehealth (video) Services Protocols
NATURE OF TELEPSYCHIATRY: Telepsychiatry is defined as the use of two-way real time-interactive audio and video equipment to provide and support clinical psychiatric care at a distance. Such services DO NOT include a telephone conversation. In short, telepsychiatry will allow the patient to receive medical care without need to visit the office.
MEDICAL INFORMATION & RECORDS: All existing laws regarding access to medical information and disseminating medical records apply to telepsychiatric care.
RIGHTS: I have the right to withhold or withdraw my consent to the use of telepsychiatry at any time during the course of my care in writing. Alternatives to telepsychiatry include traditional face-to-face sessions.
CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with telepsychiatry. All confidentiality protections that exist under federal law apply to information disclosed during telepsychiatry sessions.
In order to protect the privacy of our practitioners and patients, you agree not to photograph or record via audio, video, and/or any other means, your medical sessions whether such session is in-person, or via telepsychiatry (as defined in this document) or other patients and/or the common areas of Rainwater Psychiatric offices.
POTENTIAL RISKS: Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of audio and/or video); delays in medical evaluation and treatment due to deficiencies or failure of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face-to-face visit may result in errors in medical judgment. In the event that you are mentally compromised, due to the variability of patient location during telepsychiatry, emergency services may fail to locate and treat you.
MINORS: In addition to all protocols and parameters detailed above, the following safety protocols are recommendations of Professional Risk Management Services (PRMS):
The location of the patient will be provided by the patient to the provider so local emergency resources may be notified if necessary
The patient should have established a local provider (ex. Primary Care Physician) for situations when an in-personal evaluation may be needed and the patient is unable to travel to his/her psychiatric provider's office.
PAYMENT
You are financially responsible for all charges, whether or not insurance pays for any services, we decide to proceed with treatment, or treatment is successful, for which there cannot be any guarantee
You agree to pay professional fees as follows (unless specified in writing elsewhere):
Self-pay (not submitting in-network claims to your insurance)
Initial appointment: $350
All follow-up appointments: $195
Telepsychiatric (video) appointment fees are the same as in-office appointment fees
In-network services: Refer to consent document provided to you by Headway for further explanation of costs and other related factors to insurance billing/claims.
Non-conventional services: Telepsychiatric (video/virtual) services may or may not be covered under your insurance policy, even for an in-network provider. It is your responsibility to consult with your insurance provider about coverage eligibility prior to schedule and/or performing a telepsychiatry appointment.
The following services typically ARE NOT COVERED BY INSURANCE and WILL BE THE PATIENT'S RESPONSIBILITY (this list is not comprehensive):
Phone Consultation - only allowed in certain circumstances and excluding the no-charge pre-intake consultation: $90
No shows/late reschedule -not presenting to your appointment at least within 15minutes of appointment start time or rescheduling with less than 24hr hour notice: $75, though after repeated offenses this may be raised to full session charge.
Payment will be accepted at the time of service and in the form of check or card (including HSA cards where applicable). You will not be charged any amount prior to the date/time of your appointment (excluding charges for no shows/late cancellations)
You affirm you are an authorized user of the credit card whose number and expiration date supplied, and you do authorize its use for all fees incurred.
By typing your signature below, you confirm you have read the above and agree to these terms and conditions, including authorizing Rainwater Psychiatry NP PLLC and affiliated entities to use telepsychiatry in the course of your treatment.
Reference: Practice Guidelines: Core Elements for Responding to Mental Health Crises. HHS Pub. No. SMA-09-4427. Rockville, MD: Center for Mental Health Services, Substance Abuse and Mental Health Services Administration, 2009.