SB Integrative Psychiatry - Treatment Form and Care Agreement
I acknowledge that my initials below each statement is legally binding and represents my full agreement to the terms within each statement that I provide my initials for.
Date: *
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Last Name: *
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First Name: *
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1. CONFIDENTIALITY: I understand that all information between myself and my provider is held strictly confidential and no information about my medical/psychiatric services including diagnosis, treatment, prognosis, progress or any other confidential information will be released unless permitted by law or: a) I agree in writing to permit such a release b) I present a physical danger to myself c) I present a danger to others d) Child/Elder abuse or neglect is suspected - I understand that in cases b), c), and d) - Dr. Mantz/Dr. Le is required by law to inform potential victims and legal authorities so that protective measures can be taken. [please initial below] *
Your answer
2. RELEASE OF INFORMATION In addition to releases of information permitted above, I authorize discussion of my case with my other professional health care providers and facilities for the purposes of diagnosis, treatment, and transition of care. (Release of information to non-covered entities such as family, friends, etc, requires a separate form) [please initial below] *
Your answer
3. GENERAL CONSENT FOR TREATMENT I authorize and request that my physician carry out psychological examinations, treatments, and or/diagnostic procedures which now or during the course of my care as a patient are advisable. I understand that the purpose of these procedures will be explained to me upon my request and subject to my agreement. I also understand that while the course of therapy is designed to be helpful, it may at times be difficult and have side effects. I understand that any therapy whether it be psychotherapy, pharmacotherapy, nutritional therapy, exercise therapy, meditation therapy, or the judicious use of over the counter supplements carries with it the potential for undesirable side effects. I understand that my provider will keep a clinical record that may contain information regarding my diagnosis, treatment, progress notes, and other documents pertinent to my treatment. This record is confidential and will only be released with my written consent except in cases detailed within this agreement or within the HIPAA Notice of Privacy Practices [please initial below] *
Your answer
4. EMERGENCY PROCEDURES I understand that my provider, Michael B. Mantz, MD/Kim D.N. Le, MD may not be available for emergencies. If I need to contact my provider, I will leave a phone message according to the instructions on my provider’s confidential voicemail and my call will be returned. I agree to not use email for emergencies or urgent issues. If an emergency situation arises, I will follow the emergency procedures listed on my provider’s voicemail main message. If my call is not returned in a prompt manner and I require immediate attention, I will call 911 or go to my nearest Emergency Room. I will do this for true emergencies only. [please initial below] *
Your answer
5. CANCELLED/MISSED APPOINTMENTS I understand that a 48-hour notice is required for cancellation of any appointment to avoid being charged the full cost of the reserved session fee. I understand that I am to have an active credit card/debit card on file, and that I give permission to charge my card in the event of a no show or late cancellation from me. [please initial below] *
If you become moderate to severely ill we will waive the fee without a doctor's note the first time. An urgent care or doctor's note will be required after the first time. We are a part-time practice with only 20 hours of patient time available each week and scheduling one of these slots blocks others from having it. The 48 hour notice allows for other clients the opportunity to have it.
Your answer
6. FEES FOR FORMS, LETTERS, AND PHONE CALLS: I understand that I will be billed at a rate of $7 per minute for any clinically related matters for any outside-of-session activity including but not limited to phone calls, letters, emails and videoconferencing. I understand that Dr. Mantz/Dr. Le does not testify in court without prior arrangement. I understand that Dr. Mantz/Dr. Le does not provide insurance or disability paperwork without prior arrangement. I understand I will need to make a separate full session appointment to go over and fill out any associated paperwork. I understand that Dr. Mantz/Dr. Le is not required by law to fill out forms including disability or legal paperwork, write letters, testify or make phone calls outside the requirements set forth by the current Laws for Physicians in California. Any request for out-of-session activity not required by law will be addressed on a case by case basis and I understand that Dr. Mantz/Dr. Le may deny such a request. [please initial below] *
Your answer
7. LIMITS OF SERVICE: Dr. Mantz/Dr. Le does not provide insurance, disability or worker’s comp evaluations without prior arrangement. Dr. Mantz/Dr. Le does not testify in court or as an expert witness without arrangement. Written evaluations often require enough time to require billing at the hourly rates described in this initial legal paperwork. Dr. Mantz/Dr. Le is happy to provide psychiatric referrals upon request. If Dr. Mantz/Dr. Le does not hear from you within one month of contacting you for follow up, (s)he will assume that you are receiving adequate psychiatric care elsewhere, that you no longer require or expect his/her services, and that you are dismissing him/her as your physician. However, Dr. Mantz/Dr. Le may arrange your return to his/her psychiatric practice at a future date as is appropriate. [Please initial]
Your answer
8. PRIVACY PRACTICES I have received notice of my provider’s HIPAA (Health Insurance Portability and Accountability Act) Privacy Practices document and have read, reviewed, and understand such privacy practices of this office. [please initial below] *
Your answer
9. FINANCIAL POLICIES I understand that Dr. Michael B. Mantz/Dr. Kim D.N. Le is not on any insurance panels and is opted out of medicare insurance and that I am responsible for payment at each appointment. I am not to submit any claims to medicare. I also understand that Dr. Mantz/Dr Le may provide me a superbill upon request from me for each visit indicating the services provided and that I may submit them to my insurance plan for reimbursement. I understand that any superbill and other billing requests made after 1 month of the date of service is subject to the $7 a minute billing rate for the time it takes to generate and send the bill to me. Accepted methods of payments for services include credit, debit cards (VISA/MC/AMEX). My (the Patient/Parent/Legal guardian) account can be charged up to 48 hours before the scheduled appointment time. Checks and cash are acceptable for in-person appointments and are due at the time of the appointment. At my request, Dr. Mantz/Dr. Le will attempt to charge a Health Savings Account (HSA) credit card first. If I decide to use an HSA card I am required to have an active secondary card to be on file given the erratic nature of HSA funding and the potential for insufficient funds. I am required to keep my payment card information up to date and if the charge is declined I may be charged a $25 dollar fee after the 1st occurrence. I understand that if a check is returned for non-sufficient funds my credit card will be charged for the session as well as a $35 charge for returned checks. I understand that the fees at SB Integrative Psychiatry are subject to change and I will be given notice either through email or a written letter a minimum of 1 month before such changes take place. I agree to these policies and methods of payments. [please initial below] *
Your answer
10. Fee Structure: I understand and agree to pay for services according to the following fee schedule: -----------------------------------------------------Intake and Diagnostic Examination 80 minutes $425----------------------- Fundamental Mind-Health Sessions (typically 3) $375----------------------Establish Patient (EP) Full Session 50 minutes $375-------------------------(EP) Focused Half-session 25 minutes $250--------------------------------- (EP) Psychotherapy/MHC Session 50 minutes $325------------------------- Brief Medication/Supplement Management - Focused Phone Appointment 10 minutes $125-----------------------------------------------------------------[please initial below] *
Your answer
11. PRESCRIPTION POLICIES I understand that my doctor will prescribe enough medication to last until the next recommended visit. I will track my current supply of medication and remaining refills. I will request prescription refills either during my appointments or at least 2 BUSINESS DAYS (excluding Monday) before I run out of medication by calling my pharmacy and having them fax my doctor for a refill request. I understand that Dr. Mantz/Dr. Le is not responsible for delays and errors made by the pharmacy that I use. If my pharmacy does not follow through on faxing a request to my doctor or staff it is my responsibility to provide the office staff with my prescription information by submitting a Prescription Refill Backup Form (located on his website: https://www.mindbodyintegrationandhealing.com/resources and last resort voicemail including the following information: Full Name, Date of Birth, Name of Medication, Dosage, Time and Number of Pills per day, Pharmacy Number for each refill request sending it 2 business days before I need the medication. I agree to pay the fee of $20 for urgent refills (less than 2 business days), as indicated on this practice’s website. Policies for prescriptions for controlled substances such as sleep, anti--anxiety or stimulant medications will have additional conditions. [please initial below] *
Your answer
12. TELEPSYCHIATRY/RECORD STORAGE: I understand the risks inherent with communicating with Dr. Mantz/Dr. Le through the internet and through videoconferencing. I understand that SB Integrative Psychiatry has taken steps to provide a level of security that meets or exceeds the current recommendations set forth by the American Psychiatric Association in accordance to the current HIPAA statutes to help protect my personal health information (PHI) including using third party providers that provide encryption and other methods of security in order to provide reasonable security practices to protect my PHI. I have read, understood, and agree to the policy practices for the following vendors: Google and Microsoft for the maintenance of my electronic health record and Vsee.com or Google Hangouts for videoconferencing of our sessions. I understand that despite the security measures that these vendors provide that there is still the possibility for PHI to be breached and I accept those risks. ---------------------------------------------------------------------------------------------------------Optional: In case there are technical issues with the videoconferencing program Vsee.com or Google Hangouts - I will allow the teleconferencing of our therapy session to be conducted over Skype. I understand that even though Skype does encrypt the flow of information that it technically does not meet the requirements set forth by the current HIPAA statutes. I understand the possible risks inherent in conducting a telepsychiatric session over Skype which include, but are not limited to, possible breaches of PHI and I accept those risks. [please initial below and if you do not accept the optional Skype sessions please put the word NO next to your initials] *
Your answer
13. EMAIL/INTERNET COMMUNICATION: I understand that I may communicate with SB Integrative Psychiatry staff via internet, text or through email and I accept the risks inherent in these forms of communication, including but not limited to possible breaches of my PHI from unknown third parties. I understand that I can reduce these risks by communicating with SB Integrative Psychiatry staff via the telephone or fax instead. I also understand that I may use email communications only for brief non-urgent/non-emergency matters. I understand that emails are to be sent to the office manager only. Dr. Mantz/Dr. Le will not respond to any clinical emails directly from me in order to reduce the risk of a breach in my protected health information. Appropriate emails to office staff are for the following purposes: --------------------------------------------------------------------------------------------------------------------------------------------------------------------Billing, Prescription Requests (if Pharmacy fax refills are not available in a timely manner and contain the appropriate information: Full Name, Date of Birth, Name of Medication, Dosage, Time and Number of Pills per day, and Pharmacy Number for each refill request), Scheduling, Letter and Form requests, and Email consult requests. Clinical issues whether non-urgent or urgent are best handled by telephone and will not be accepted for email use. For these matters I agree to use the telephone instead. ----------------------------------------------------------------------------------------------------------------------------------------------------------------------I understand that the telephone is the safest way to communicate with Dr. Mantz/Dr. Le and office staff for any out-of-session issues or concerns. I understand that clinical issues are most appropriately handled through telephone communication and that emails concerning clinical matters will not be responded to. -------------------------------------------------------------------------------------------------------------I understand that SB Integrative Psychiatry telephone office hours and staff email hours are Tuesday - Friday: 10am - 4pm. Telephone messages left after Friday 4pm will be responded to on the following Tuesday. I understand that Dr. Mantz/Dr. Le runs a part-time clinic. If I am unable to reach him/her for some reason regarding an urgent (but not life-threatening) issue, I may also consider calling my internist or family physician. For all emergencies I will call 911 or go to my nearest emergency room. [please initial below] *
Your answer
14. APPOINTMENTS and MEDICATIONS: I understand that if I am an established patient that is receiving prescriptions through Dr. Mantz/Dr. Le that I am required to make at least one full or half session appointment every 60 days/2 months in order to continue to receive refills. (it is recommended for those patients who make less frequent appointments to schedule their follow-up appointments at each appointment to make this a non-issue). I understand that I will not receive medication refills if I don't make an appointment at least once every 60 days. [please initial]
Your answer
15. SUPPLEMENTS and NUTRITIONAL TREATMENTS: Because some nutrients and vitamins should not be taken without continued monitoring, and new research is occurring in this field everyday, nutrients and vitamin recommendations during our work together shall expire 12 months from the initial recommendation unless otherwise discussed. I have read and understood this policy. [please initial]
Your answer
16. If my condition is deteriorating, or I need to be seen before the next scheduled appointment for any reason, it is my responsibility to contact Dr. Mantz/Dr. Le's office. If I do not make an appointment with Dr. Mantz/Dr. Le at the end of a session, it is my responsibility to contact their office within an agreed upon time frame. Because patients in psychiatry will sometimes return to their internists for baseline psychiatric care, if Dr. Mantz/Dr. Le contacts me and I do not respond back within 30 days Dr. Mantz/Dr. Le will assume I am getting my care elsewhere. [please initial]
Your answer
17. GOOGLE FORMS: I understand that SB Integrative Psychiatry uses a HIPAA compliant professional Google Suite platform and that my google form responses are encrypted and stored with privacy protection at a level that meets or exceeds the requirements set forth by the HIPAA laws. I understand that despite the security measures that Google Suite provides that there is still the possibility for my PHI to be breached and I accept those risks. Also I understand that if I accept to have my responses emailed back to me that my response email and it's information are no longer covered by SB Integrative Psychiatry HIPAA compliant platform and its privacy protection responsibility becomes mine and the email system that I use. I understand that most email systems offer encryption and various levels of privacy protection but can be susceptible to possible breaches and are not HIPAA complaint. (You can increase your privacy protection if you decide to track and receive your google form responses by downloading them on to your computer and then deleting the response email.) [please initial]
NOTE: Most email systems offer encryption and various levels of privacy protection. Please check with your email provider for more information. You can increase your privacy when receiving your google form responses by downloading them on to your computer and then deleting the email.
Your answer
Thank you for taking the time to fill out this form. If you have any questions please call us at 805-679-3034 or email us at admin@sbintegrativepsychiatry.com. We are excited to bring you the best in mind-health and to have you as one of our clients.
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