Informed Consents to Treatment, Practice Fees and Policies
WELCOME TO TOTAL WELLNESS CENTER
We Look Forward to Meeting all of Your Mental Health and Wellness Needs
A – Payment, billing and medication refills:
Total Wellness Center is a private outpatient mental health practice that is based on a fee for service model. We accept many major commercial insurances along with cash/credit card/check payments for services. If you are using insurance, your benefits will need to be verified prior to your visits. If your insurance is inactive, please update prior to your visit so the benefits can be verified. If verification is not able to be done by the date of your visit, you will be required to pay at the time of service. If insurance is later verified to be active and billed for the date of service, we will be happy to refund your fees.
You will be responsible for any charge not covered by insurance. This includes, but is not limited to, co-insurance, co-payments, and deductibles.
Accepted methods of payment:
Self-Pay
All patients who pay private fees are expected to pay in full at the time of service. Payments can be in check, cash and/or credit/debit/HAS card at the time of service. We can also combine various forms of payment if this is more convenient and/or preferred by the patient.
Private Insurance
We are a participating provider with some health insurance companies, and will bill those health insurance companies for the payment amount agreed upon by contract on your behalf. Should you wish to use private insurance to pay for services, you will be asked to provide your insurance card so that our office may make a copy for its records. Our office will submit bills in the forms of claims to your insurance company. You are expected to pay your co-pay, which is established by your respective insurance company, at the time of service. We will verify if our practice is considered in—network or out-of-network prior to your visit, and inform you so that you are aware of your co-pay/co-insurance and deductibles at the time of your visit. Please review and be informed of these items with your individual policy. Total Wellness Center is not able to change the fees insurance companies set for your out of pocket costs.
If your insurance company does not agree to pay for your medical services, you will be liable for the fee that is set. It is our policy and expectation that patients will pay their fee at the time of service. However, if a bill is generated, it is the expectation that the patient will pay this bill upon receipt. Patients will be billed on a monthly basis. We are happy to discuss any billing issues that may arise during treatment.
Insurance Billing.
By signing this document, you are agreeing to allow Total Wellness Center to bill your insurance on your behalf.
Past Due Balance
A past due balance is a balance owed to our office for at least 30 days or one full billing cycle. Bills that exceed 90 days will be turned over to a collection agency unless previous arrangements have been made with Total Wellness Center directly.
Late Cancel or No Show Appointments
If you are unable to make an appointment, we kindly ask you to inform Total Wellness Center, preferably within 24 hours prior to your appointment. It is our general policy that if an appointment is canceled with less than a 24-hour notice, or you do not come to your appointment [no show], a $50.00 (fifty) fee will be charged. We are aware emergencies do arise, and will work with you to reschedule your appointment and avoid associated late fees.
Prescription Refill Requests
Medication prescriptions are given during your appointment with the appropriate number of refills lasting until the next scheduled appointment [generally between 1 and 3 months]. If for some reason you are unable to make your scheduled appointment, and do need medications outside of your visit, please contact our office and we may provide enough medication to last until your next visit. If any of our clinicians deem it necessary to have an encounter prior to authorizing medication refills, you may be required to speak with one of our clinicians for an update on your medical and/or mental health condition. Total Wellness Center does utilize electronic prescribing, and when applicable, prescriptions will be sent through that system. In some situations, such as with controlled substances, the medication may be denied for refill until you are able to meet for an appointment.
B – General Policies and Practices
You will be able to discuss with your mental health provider clinical observations regarding the presenting symptoms, issues, diagnosis or diagnoses, benefits/limitations of treatment, and treatment interventions and expectations proposed including risks and benefits to such treatments.
You will be given a clear description of the types of treatment recommended, such as pharmacological treatment, individual counseling/therapy, group counseling/therapy, family/couples counseling/therapy, addiction counseling, partial hospitalization, intensive outpatient programs, and inpatient/outpatient treatment.
You are voluntarily agreeing to engage in mental health treatment and understand that you may end treatment at any time. You understand that your mental health provider may want to discuss this with you, but that you reserve the right to stop treatment. Furthermore, you understand that your mental health provider may make diagnostic and treatment recommendations with which you may not agree (e.g. modality of treatment, duration of treatment, frequency of visits, etc.), and that your provider may refer you to other clinicians outside of Total Wellness Center who may better be able to address your concerns/needs.
Lastly, the clinicians reserve the right to refuse treatment to anyone if they do not feel it is appropriate to engage in treatment or is not clinically indicated. In these instances, the clinicians will make every effort to refer patients to the appropriate treatment facilities and/or providers who may be better able to meet the patient’s mental health needs.
In the United States, the only time a patient has a right to care is when that patient needs true emergency care and accesses the emergency room of a hospital that accepts federal money through Medicare (see EMTALA.) Even then, if a patient is deemed not to require emergency care, he may be refused care and told to see his primary care physician or to check in with an urgent care clinic.
You understand that your mental health provider cannot guarantee results (e.g., less depressed, improved marital satisfaction, etc.) of mental health services. However, there will be clearly stated reasons, goals, and objectives for continuing/discontinuing mental health treatment. This can be discussed further with your mental health provider.
You understand that there may be some risks in participating in mental health services. These may include, but are not limited to, addressing painful emotional experiences and/or feelings or being challenged or confronted on a particular issue.
Every effort will be made to maintain professional integrity and appropriate treatment parameters and address mental health issues in a thoughtful and respectful manner at all times with the ultimate goal always being to heal, treat, and overcome mental health concerns/issues and re-establish health and wellness.
You are aware that you can discuss any risk, expected or unforeseen, vs. benefits with your mental health provider at any time. In the case of psychiatric care, medications, side effects, and alternative treatments can be discussed. Specific information regarding available research and standards of practice for mental health treatment, for example during pregnancy and the postpartum period, can also be discussed as part of your treatment plan.
You understand that this Informed Consent is not intended to be “all inclusive” of your mental health treatment. It is only intended to provide useful information before deciding to engage in mental health treatment.
You understand there is an inherent risk associated with being pregnant and there are risks associated with mental health issues in pregnancy and postpartum. There is evidence to say there are also risks with both the treatment and lack of treatment of these issues during pregnancy and postpartum. Any concerns in this regard can be discussed with your clinician during the course of your treatment.
You understand that Total Wellness Center does not provide emergency services. If an emergency arises, you are directed to seek the nearest emergency room and/or call 911 for immediate medical attention.
Please inform our office after you have been seen and/or evaluated emergently, and we will schedule a follow up outpatient appointment as soon as possible and/or clinically appropriate to ensure continuity of your care.
Total Wellness Center provides services by appointment only; we do not offer “walk-in” services.
C – Limits of Confidentiality
The information that you share with your Mental Health Provider is considered to be confidential and protected under the HIPPA mandate.
HIPAA: Acronym that stands for the Health Insurance Portability and Accountability Act, a US law designed to provide privacy standards to protect patients’ medical records and other health information provided to health plans, doctors, hospitals and other health care providers. Developed by the Department of Health and Human Services, these new standards provide patients with access to their medical records and more control over how their personal health information is used and disclosed. They represent a uniform, federal floor of privacy protections for consumers across the country. State laws providing additional protections to consumers are not affected by this new rule.
In most cases, information cannot be released to another party without your written consent. However, in certain circumstances, information can be shared legally without your permission. These circumstances include:
Suicide: if you are assessed to be a danger to yourself; cannot guarantee your physical safety against the intention of suicide; and/or have immediate suicidal plans, this information is not considered to be “confidential”. Actions may be taken to ensure your safety.
Homicide: if you are assessed to be a danger to others; cannot guarantee their safety; and have immediate, specific plans to cause fatal injury/harm to another person, this information is not considered to be “confidential”. Actions may be taken to protect the safety of others.
Court order/subpoena: Your Mental Health Provider(s) may be required to relinquish a copy of your written Mental Health Record to the appropriate Courts. Mental Health Providers can also be subpoenaed to testify in court without your consent.Child abuse/neglect: Your Mental Health Provider is required to report to the appropriate authorities (i.e. Child Protective Services) any suspicion or evidence of past and present child abuse or neglect.
Mental Health confidential information may also be used in a number of ways within Total Wellness Center and Total Wellness Center without your specific written permission for coordinating services and delivering quality care. You will be informed if this is the case. These may include:
Consultations and case conference with other providers at Total Wellness Center, including staff who assist in facilitating patient information and care with clinicians.For billing purposes: a diagnosis is given to your insurer for reimbursement purposes, medical assistance and commercial insurance.
D – Informed Consent for Telemedicine Services
PURPOSE: The purpose of this document is to obtain your consent to participate in a telemedicine consultation, provided by the Physicians, Psychiatric nurse practitioners, Social workers and Professional counselors of Total Wellness Center, in connection with the following procedure(s) and/or service(s):
Psychiatric Diagnostic Examination with or without medical servicesPharmacologic managementIndividual, Group and Family psychotherapy
You understand that telemedicine is the use of electronic information and communication technologies by a healthcare provider to deliver services to an individual when he/she is located at a different site than the provider; and hereby consent to Total Wellness Center clinical staff to provide health care services to you via telemedicine.
You understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine. As always, your insurance carrier will have access to your medical records for quality review/audit.
You understand that you will be responsible for any copayments or coinsurances that apply to your telemedicine visit.
You understand that you have the right to withhold or withdraw your consent to the use of telemedicine in the course of your care at any time, without affecting my right to future care or treatment. You may revoke your consent in writing at any time by contacting Total Wellness Center by fax (+1(201) 353-2514) or e-mail (). As long as this consent is in force (has not been revoked) you may receive health care services via telemedicine without the need for you to sign another consent form.
E – Communication by Email, Text Message, and Other Non-Secure Means
It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication that, in their typical form, are not confidential means of communication. If you use these methods to communicate with your clinician, there is a chance that a third party may be able to intercept and eavesdrop on those messages. The kinds of parties that may intercept these messages include, but are not limited to:
- People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages
· Your employer, if you use your work email to communicate with your clinician
· Third parties on the Internet such as server administrators and others who monitor Internet traffic.
If there are people in your life that you don’t want accessing these communications, please talk with your clinician about ways to keep your communications safe and confidential. Attention: Telemedicine services are provided by secure and HIPAA compliant online software and are excluded from this communication and consent.
F – CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
You consent to allow Total Wellness Center staff and clinicians to use unsecured email and mobile phone text messaging to transmit to you the following protected health information: · Information related to the scheduling of meetings or other appointments · Information related to billing and payment · Acknowledgment of emails and phone calls received · Other reports
You have been informed of the risks, including but not limited to your confidentiality in treatment, of transmitting your protected health information by unsecured means. You understand that You are not required to sign this agreement in order to receive treatment. You also understand that you may terminate this consent at any time.