PFHL Office Policies
Welcome to our practice. The following policies will help you understand our processes and
procedures. Please AGREE to each section and SIGN and DATE at the end.
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(First and Last) Name of Patient: *
Date of Birth of Patient:   *
(First and Last) Name of Person Completing This Form: *
Relationship of Person Completing This Form to Patient: *
INFORMED CONSENT/TREATMENT AUTHORIZATION:  By agreeing, you acknowledge that you have received copies of the Notice of Privacy Notices and Informed Consent for Treatment (both found at: of Providers for Healthy Living and its providers and were given the opportunity to answer clarifying questions to your satisfaction (by calling 614-664-3595 or emailing patient@providersforhealthyliving). After weighing the benefits and risks, you hereby give your consent for evaluation and treatment by Providers for Healthy Living and its providers. *
INSURANCE BENEFITS REASSIGNMENT AUTHORIZATION AND REIMBURSEMENT:  If you have a health benefits insurance policy, it may provide mental health coverage. It is your responsibility to contact your insurance company to obtain prior authorization for services provided. Please be aware that most insurance agreements require you to authorize us to provide a clinical diagnosis, and sometimes additional clinical information such as treatment plan or summary, or in rare cases, a copy of the entire record. We are required to submit this information on your behalf if you choose to obtain insurance reimbursement. In cases where your insurance does not pay for your or your child's session through no fault of ours (including lack of medical necessity or prior authorization), you will be billed directly and will be expected to pay the current self-pay rate for that service. By agreeing here, you assign your insurance benefits (current and future), if any, to Providers for Healthy Living and its providers, otherwise payable to you for services rendered. You further authorize the use of your signature on all insurance submissions. *
CONTACTING US:  Our phone number at 614-664-3595 is monitored at all times. We will make every effort to return your call on the same day you make it with the exception of weekends and holidays. When you call, please leave some times and phone numbers where you can best be reached. If you are calling and consider the call an emergency, there are instructions on the voice mail with numbers to calls for emergency help. Please DO NOT leave a message in case of an emergency as these situations are best handled by calling 911 or going to the nearest ER. With respect to electronic mail (e-mail), please be aware that while all of our providers are available via e-mail, it is not a confidential means of communication. Furthermore, we cannot ensure that e-mail messages will be received or responded to in a timely fashion as we check our e-mail on an irregular basis. E-mail is not an appropriate way to communicate confidential information or emergency issues or urgent issues that need to be handled after regular clinical hours. *
CANCELLATIONS AND MISSED APPOINTMENT POLICY:  Once your appointment is scheduled, you will be expected to attend unless you provide at least 24 hours advanced notice of cancellation. If you do not provide at least 24 hours notice, or fail to show for a scheduled NEW medication or therapy appointment, you will be responsible for a $150 no-show charge and if you fail to show for a scheduled FOLLOW-UP appointment, you will be responsible for a $100 charge. Missing a group will result in a $30 charge, and missing a testing appointment will result in a $275 charge. Please note: this fee must be paid before future appointments will be scheduled or medication refills will be given. If you arrive late and miss half of your scheduled appointment time, you will be rescheduled.  Please note, these fees may change over time as PFHL's discretionary. *
EXCESSIVE NO SHOWS OR LATE CANCELLATIONS:  Consistency is the key to improving and maintaining your or your child's mental health. To this end, if your absences (late cancellations or no shows) become clinically interfering, you or your child will likely be dismissed from our practice. A certified letter will be sent notifying you of this decision, in the unfortunate and unlikely event that this may occur. *
BILLING AND PAYMENTS:  You are expected to pay appropriate co-payments, deductibles, and account balances for each session at the time of the appointment. We accept cash, checks, and credit cards for payment. Services will not be rendered if payment is not made and appointments cannot be scheduled until balances are paid in full. If your account has payment overdue for over 60 days, we have the option of referring your account to a collection agency and closing your account with our office. There is a $26 returned check fee for all unpaid/returned checks. *
CHARGES FOR PHONE CALLS AND EMAILS:  We do not make medication changes over the phone except in emergency situations. If medication changes are made during email or phone exchanges that would’ve otherwise been made during an office visit, you will be billed for an equivalent session and you will be responsible for any fees associated with these billed sessions as insurance generally doesn't cover these charges. Likewise, phone calls with a therapist that would otherwise have been conducted in the office will be billed, and you will be required to pay for these sessions. *
PRESCRIPTION REFILLS:  It is your responsibility to call in advance for medication refills. Refill requests should be placed online via our website at least 48 hours in advance. Medication refills are not considered emergency phone calls on weekends or after hours. Please monitor your medications closely and plan accordingly by calling in advance. We do our very best to provide medication coverage from one visit to the next. If you miss an appointment, you will likely run out of medication. If this happens, we will prescribe enough medication to cover until your next scheduled appointment. Some medications cannot be called in to the pharmacy or sent electronically. These medications require you to physically come to the office to pick up a prescription. Controlled prescriptions (all stimulants for ADHD, most sleep medications, and benzodiazepines for anxiety) are regulated by the federal government and cannot be filled early regardless of the reason. No refills will be given if you haven't been seen in the past 90 days, so please schedule and keep regular appointments to avoid this unfortunate situation. *
PAPERWORK/LETTERS/DISABILITY FORMS:  We have decided as a practice to charge a fee to complete forms, letters, and disability paperwork. Disability forms, FMLA paperwork, letters for school and work, etc. may be completed by the clinician, if appropriate, but payment in advance is expected based on the number of pages and the complexity of the documentation. In general, our practice does not support patients being off work for disability. It is our goal to help patients function at their best, and supporting a disability claim is a direct contradiction to our mission. Therefore, we will not complete disability forms unless we recommend the process. We will, however, provide records in all cases, if requested. *
CONFIDENTIALITY:  Confidentiality is important, lawful, and necessary for appropriate mental health care. There are some exceptions when we are required by law to break confidentiality, however: (a) to take appropriate steps to ensure your safety if there is a threat of self-harm, (b) to take appropriate steps to ensure safety of others if there is a threat of harm to others, (c) to report child, elder, or dependent abuse, and (d) legal testimony if subpoenaed by a court. These exceptions are rare, and we do our best to maintain confidentiality. Otherwise, no information is given to anyone without your consent. Without a signed release of information from all individuals 18 or older, no information can be released without their consent, except under court order. *
DISRUPTIVE OR ABUSIVE LANGUAGE/BEHAVIOR:  We strive to create and maintain a respectful environment at all times, and expect the same from all interactions we have with patients. Any profanity, abusive language or behaviors, demeaning comments, disruptive behaviors, threatening remarks, etc., will not be tolerated, and may lead to immediate dismissal from our practice. *
TEENAGERS:  I give permission for my teenage child to attend THERAPY sessions without me. I also understand that this DOES NOT apply to MEDICATION visits, where a parent/guardian and child must alway be present together. *
DECLARATION:  I have read the above policies and fees and agree to be held by them. I was given the opportunity to ask clarifying questions to my satisfaction. If the parent of a minor, by signing below, I indicate that I am the custodial parent and am authorized to make final treatment decisions on my child’s behalf. If not the custodial parent, a copy of the divorce decree will be required before your child can be seen. *
By typing your name below, you certify that you have read and agree to all the policies outlined above, and agree to be held by the consequences of these acknowledgments.  (Please type the full legal name of the person completing this form.  By doing so, you agree that your typed signature has the same validity and meaning as your handwritten signature.) *
Date Signed: *
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