Please review this policy if you plan to schedule an appointment or are already a patient!
APPOINTMENTS AND CANCELLATIONS
You are responsible for attending each appointment and agree to adhere to the following policy: If you cannot keep the scheduled appointment, you MUST notify our office to cancel or reschedule the appointment within 24 hours of the scheduled appointment time. The first no-show/late cancellation will be waived. The second no-show/late cancellation will result in a $75.00 fee to reschedule an appointment. If you cancel or reschedule more than once, we may re-evaluate your needs, desires, and motivations for treatment at this time.
We are in-network with some insurance plans and are in the application process for other major insurances.
Co-payments, coinsurances, and deductibles are expected before your visit with the provider. In the event that your insurance is “out-of-network, we will provide a detailed receipt, called a “superbill” which can be submitted to your insurance company for possible reimbursement. Please consult with your insurance company for any questions prior to your visit.
Controlled substances are prescribed sparingly in this practice in an effort to keep you safe. They are also highly regulated by the Drug Enforcement Agency (DEA). My prescribing of such medications is monitored, and providers are held accountable for prescribing practices. State laws require that additional measures be taken when prescribing controlled substances. We want our clients to know how seriously we take the prescribing of these types of medications.
It is the expectation of this practice that the controlled medication will be taken as prescribed and not self-adjusted. This means you will not increase or decrease your dose or stop taking it without talking to your prescribing provider.
Self-adjusting controlled substances will be considered non-compliance. This type of non-compliance will result in discharge from our practice, as it places a huge liability on our ability to safely manage your care.
CONTROLLED MEDICATIONS WILL NOT BE REFILLED EARLY.
It is your responsibility to take them only as prescribed. Insurances will also not pay for them to be filled early. Please do not call the office asking for them to be refilled early.
CONTROLLED MEDICATIONS WILL NOT BE REPLACED
It is your responsibility to make sure that your medication is kept in a secure place to prevent loss or theft. If you report to our office that your controlled medication(s) has been lost, misplaced, or stolen, it will not be replaced.
Disability Forms Policy
The client must have been a client of this office for at least 6 months for long-term disability or SSI forms to be completed. We are happy to provide your medical records, but we will not make the determination if you qualify for long-term disability.
A client must have completed two visits for short term or FMLA forms to be completed.
Paperwork can take up to 14 days for completion. It may be completed earlier, but it is done on a first come first served basis. Please understand it is difficult to rush this process due to the limited staff available to complete these forms.
Clients must be compliant with on-going treatment including medications and keeping appointments to have the office to continue filling out disability forms.
Clients must have seen the provider within the last 30 days to submit disability paperwork.
Blank forms will not be accepted: At a minimum the client’s name and date of birth should be filled out on the form prior to submission.
There is a charge to fill out these forms: $50- $150 depending on length of form is due before the form is returned to the client.
PHONE CONTACTS AND EMERGENCIES
Office hours are from Monday – Friday 9am – 5pm CST
If you need to contact the clinician for any reason during these hours, please text or call 901- (901) 602-2935, leave a voicemail, and a return call will be made as soon as possible. In case of an emergency, you can access emergency assistance by calling the National Suicide Prevention Lifeline at 1-800-273-8255. Text HOME to 741741 from anywhere in the United States, anytime, about any type of crisis. Crisis Text Line serves anyone, in any type of crisis, providing access to free, 24/7 support and information via a medium people already use and trust. If either you or someone else is in danger of being harmed, dial 911 or go to your nearest emergency room.
Dismissal from Practice
We reserve the right to dismiss any patient from the practice for any of the following reasons
Each individual’s situation is different, and dismissal from the practice is reserved as a last resort. Whether or not to dismiss a patient is at the provider’s discretion.
This document contains important information about federal law, the Health Information Portability and Accountability Act (HIPAA), that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations.
HIPAA requires that we provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice explains HIPAA and its application to your PHI in greater detail.
The law requires that we obtain your signature acknowledging that we have provided you with this. If you have any questions, it is your right and obligation to ask so we can have a further discussion prior to signing this document. When you sign this document, it will also represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding unless we have taken action in reliance on it.
Use and Disclosure of Protected Health Information
For Treatment – We use and disclose your health information internally in the course of your treatment. If we wish to provide information outside of our practice for your treatment by another health care provider, we will have you sign an authorization for release of information. Furthermore, an authorization is required for most uses and disclosures of psychotherapy notes.
For Payment We may use and disclose your health information to obtain payment for services provided to you.
For Operations – We may use and disclose your health information as part of our internal operations. For example, this could mean a review of records to assure quality. We may also use your information to tell you about services, educational activities, and programs that we feel might be of interest to you.
For HIV Disclosure– Under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, public health authorities are authorized to collect and receive private health information “for the purpose of preventing or controlling disease” and in the “conduct of public health surveillance…” without patient or provider consent or authorization other than state or local public health law. This clause authorizes providers to report HIV/AIDS cases to the HIV Epidemiology Program without obtaining patient consent and it authorizes health department personnel to review medical records and any other source of information needed to report the case.
Any other disclosure of HIV-related information must be made on the “HIPAA- Compliant Authorization for Release of Medical Information and Confidential HIV-Related Information”. State law prohibits any further disclosure of HIV-related private health information without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
Right to Treatment – You have the right to ethical treatment without discrimination regarding race, ethnicity, gender identity, sexual orientation, religion, disability status, age, or any other protected category.
Right to Confidentiality – You have the right to have your health care information protected. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will agree to such unless a law requires us to share that information.
Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.
Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations.
Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI. Records must be requested in writing and release of information must be completed. Furthermore, there is a copying fee charge of 1.50 per page. Please make your request well in advance and allow 2 weeks to receive the copies. If we refuse your request for access to your records, you have a right of review, which we will discuss with you upon request.
Right to Amend – If you believe the information in your records is incorrect and/or missing important information, you can ask us to make certain changes, also known as amending, to your health information. You have to make this request in writing. You must tell us the reasons you want to make these changes, and we will decide if it is and if we refuse to do so, we will tell you why within 60 days.
Right to a Copy of This Notice – If you received the paperwork electronically, you have a copy in your email. If you completed this paperwork in the office at your first session a copy will be provided to you per your request or at any time.
Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI regarding you. On your request, we will discuss with you the details of the accounting process.
Right to Choose Someone to Act for You – If someone is your legal guardian, that person can exercise your rights and make choices about your health information; we will make sure the person has this authority and can act for you before we take any action.
Right to Choose – You have the right to decide not to receive services with us. If you wish, we will provide you with names of other qualified professionals.
Right to Terminate – You have the right to terminate services with us at any time without any legal or financial obligations other than those already accrued. We ask that you discuss your decision with us in session before terminating or at least contact must be made by phone letting us know you are terminating services.
Right to Release Information with Written Consent – With your written consent, any part of your record can be released to any person or agency you designate. Together, we will discuss whether or not we think releasing the information in question to that person or agency might be harmful to you.
We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will provide you with a revised notice in office during our session.