Salvage Psychiatry Telepsychiatry (Practice Handbook)

BILLING, FEES, APPOINTMENTS, NO-SHOWS, TARDNESS, CANCELLATIONS

Please remember to cancel or reschedule appointment 24 hours in advance. You will be responsible for the entire visit fee, if cancellation is less than 24 hours. You are responsible to set the type of appointment reminders to receive through the mandatory portal.
Practice consents, new patient intake questionnaires, and insurance name and identification/group numbers MUST BE completed at least 48 hours prior to your scheduled appointment.
You have a 15-minute grace period prior to being considered a No-Show and/or Late. Showing up for an appointment after the 15-minute grace period is considered late. You will be charged the entire visit fee.
The standard meeting time for appointments are between 15-60 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the session needs to be discussed with the provider in order for time to be scheduled in advance.
A $20.00 service charge will be charged for any attempted payments via credit card and payments returned for any reason by bank for special handling.
Clients using credit card payments for cash pay visits will be charged an additional $5.00 transaction fee.
Cancellations and re-scheduled appointments will be subject to a full charge by Sound Wellness Telepsychiatry if NOT RECEIVED AT LEAST 24 HOURS ADVANCED NOTICE. If you are located in a different time zone, you are responsible to visit Sound Wellness Telepsychiatry on an Eastern Standard Time Zone. This is necessary because a time commitment is made to you and is held exclusively for you.
If you are late for an appointment within your 15-minute grace period, you may lose some of that appointment time.
** You are responsible to contact your insurance carrier to verify your tele-psychiatry (videoconference) eligibility benefits. If you have an appointment and seen during your scheduled appointment time then realize your insurance DOES NOT cover your scheduled visit. You will be charged the full visit costs. **
All outstanding balances are expected to be paid in full at the time of your scheduled appointment.
If you have deductibles to meet prior to your insurance paying visit costs. You are responsible for all visit charges.Credit Card Authorization: Upon receipt of entering my credit card information and my signature, I authorize Sound Wellness Telepsychiatry to bill all charges for which I am financially responsible, including no-show visits. I further understand that my credit card will be charged for any outstanding balance including a 1.5% interest late charge with no waiting period. Subsequently, I authorize {Sound Wellness Telepsychiatry} to bill my account balance to my credit card immediately, and thereafter in the event a balance exists. I understand that my credit card will not be charged if I choose to pay for treatment in person at the time of each appointment.
I will notify Sound Wellness Telepsychiatry immediately charge any changes to my credit card. I acknowledge that I am fully responsible for all services received and any late fees accrued at Sound Wellness Telepsychiatry.
You are responsible for any unpaid balances.

DISABILITY, TRANSPORTATION, UTILITY COMPANY, etc. PAPERWORK

** Paperwork completion for disability of any kind and/or paperwork for community resources will cost $50 -100.00 per occurrence. Paperwork of any kind will not be completed prior to at least 6-9 months frequent and completed visits. Full compliance with appointments is mandatory for paperwork completion. ** Letter request fee for work, school, etc. is $50-100.00 per request. Correspondence may take up 5-7 days to be completed.

WE DO NOT COMPLETE TOTAL AND PERMANENT DISABILITY PAPERWORK, however, YOUR RECORDS

and/or A DIAGNOSIS LETTER CAN BE PROVIDED. We may consider a temporary disability paperwork; this will vary on a client-to-client case basis. Please know that you may utilize your psychologist, therapist or counselor for the completion of disability paperwork.

PRICING FOR SELF-PAY TELEPSYCHIATRY SERVICES

$225 – Initial Assessment /Psychiatric Diagnostic Evaluation
$125 – Medication Management with refills
$90 – Routine /Follow-up visits
$145 – Follow-up visits for Controlled medications
$250 – Suboxone Induction
$150 – Suboxone Monthly Maintenance Therapy
$125 /20 mins - Telephone consultation Calls

If the plan that you have is not included in the above list, please don’t hesitate to talk to us for your queries or clarifications by emailing soundwellnesstelepsyc@gmail.com.

ALL SCHEDULED VISITS

If your medications require you to return monthly for refills, you are expected to pay a $125.00 monthly visit charge (self-paying clients). Otherwise, your health insurance may cover telehealth visit, you will only be required to pay a co-pay fee.
You may be required to return at least bi-weekly for medication evaluations.
Three no-shows will jeopardize your ability to continue receiving care from Sound Wellness Telepsychiatry.
You are responsible for selecting appointment notification reminders by way of text, voice and/or email appointment reminders. You have to select the form of preferred appointment reminders. If you are unable to keep your appointment, please have the courtesy to cancel your appointment at least 24 hours in advance.

MEDICATION REFILLS

Medication refill outside of appointment schedule requires a $35 fee.
Schedule an appointment if you are having side effects with your medications. Medications will NOT be adjusted or changed without a visit.

TELEPHONE ACCESSIBILITY

If a true emergency arises, please call 911 or any local emergency room.
Telephone consultation calls are available. $125.00 /20 minutes increments ($375.00/hour) will be charged for non-members/non-clients outside of routine scheduled evaluation/medication management appointments.

SOCIAL MEDIA AND TELECOMMI-NICATION

Due to the importance of your confidentiality and the importance of minimizing dual relationships, I do not accept friend or contact requests from current or former clients on any social networking site (Facebook, Linkedln, etc.). I believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION

I cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, I will do so through secure messaging within the client's portal. While I may try to return messages in a timely manner, I cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine by the State of Ohio, Maryland, Arizona and Oregon. Under the Ohio, Maryland, Arizona and Oregon's Telemedicine Act, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your provider chose to use information technology for some or all of your treatment, you need to understand that:

You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled.
All existing confidentiality protections are equally applicable.
Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee.
Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent.
There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access to up-to-date information, consultations, support, reduced costs, improved quality, change in the conditions of practice, improved access to treatment, better continuity of care, and reduction of lost work time and travel costs. Effective treatment is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Providers may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the provider's inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the provider not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the provider.

TERMINATION

Ending relationships can be difficult. Therefore, it is important to have a termination process in order to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment if I determine that the psychiatric treatment is not being effectively used, you need a higher level of care, for aggressive behavior or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons in-person or notifying you by certified mail and purpose of terminating.

If you are non-compliant with mandatory treatment recommendation (labs, PCP visits, urine drug screens, follow-up visits, etc.) or if you need a higher level of care, you are subject to a termination. If treatment is terminated for any reason or you request another provider, I will provide you with a list of qualified mental health providers to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment every 90 days, unless other arrangements have been made in advance, for legal and ethical reasons, I must consider the professional relationship discontinued.

BY SIGNING BELOW, 1 AM AGREEING THAT 1 HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.