Farrah Thornsberry, PHMHNP
Psychiatric Nurse Practitioner
INFORMED CONSENT & PRACTICE GUIDELINES
Psychiatric Nurse Practitioner
INFORMED CONSENT & PRACTICE GUIDELINES
Thank you for selecting this practice for you and/or your family member’s mental health care needs. The purpose of this document is to provide you with information about professional services offered and business guidelines. Please read the information carefully. At the end of the document there are five areas for the patient or the patient’s legal guardian to initial indicating that the responsible adult has read and understands each section and then a signature line for the patient/legal guardian to sign. Please feel free to ask any questions. By signing this agreement, you are consenting to treatment at Farrah Thornsberry, Psychiatric & Mental Health Services and acknowledging the relationship developed at this practice is a safe, private, and professional one.
A psychiatric evaluation is a valuable tool employed by a psychiatrist or psychiatric mental health nurse practitioner to diagnose problems with memory, mood, thought processes and behaviors. It helps the provider get a better perspective of the problems/concerns and helps determine the most accurate diagnosis, as well as giving direction to proper treatment.
Aims of the psychiatric evaluation are:
Identify current symptoms and problems the client is experiencing that led them to seeking help now
Rule out any possible medical causes for the symptoms
Include the patient in the decision-making process
Identify problems that may emerge in the future
Discuss and develop a treatment plan with the client that is individualized and meets the client’s needs
Psychiatric medications can be used alone or in conjunction with psychotherapy to treat many conditions. In some situations, it may be appropriate to have one provider managing your medications and another provider managing your psychotherapy. Depending on what is best for you and which is the most viable option, I will work with you to find a therapist that is the best fit. It is important for us to discuss what symptoms we are targeting with the medication and how to monitor for medication effectiveness (is it working) and expected outcomes. Like all medications, psychiatric medications have the potential for side effects. I want to make sure you understand the medications prescribed to you and will discuss with you:
Benefits of the drug, procedure, or service.
Risks of the drug, procedure or service.
Alternatives to the drug, procedure, or service.
Inquiries about the drugs, procedures, services are the patient’s, parent or legal representative’s right and responsibility.
Decision to refuse the drug, procedure, and service without penalty is the patient’s, parent or legal representative’s right.
Explanation of the drug, procedure, service is owed to the patient, parent or legal representative.
Documentation that the health professional has covered each of the previous six points, usually by use of a consent form or statement.
Psychotherapy is a powerful treatment tool that can be helpful either alone or in combination with medication management. Benefits can include stress reduction, improved relationships, resolution of specific problems, development of positive coping skills and deeper insight into one’s own life, values, and goals. Therapy can at times elicit uncomfortable thoughts or feelings when you begin to explore potentially unpleasant areas or parts of your life. These feelings are usually temporary, but it is extremely important for you to discuss them when present.
Some types of therapy, such as EMDR, Havening, or DBT require specialized training and expertise. Depending on your individual needs, if you are a potential candidate for one of these services, we will work together to locate a therapist who offers these specialized therapies.
CONTACTING THE OFFICE/PROVIDER
The office is open Monday – Thursday 9:00 am – 4:30 pm. The office will be closed on most major holidays.
Please leave a message via email at email@example.com. Due to the nature of patient visits and the importance of minimizing interruptions; returned calls will be limited throughout the day and may be returned the next business day. If you are having an emergency, please call 911 or go to your nearest emergency room.
Any calls made outside of the regular office hours will be returned on the next scheduled business day. Please note that if calls are made outside of regular hours insurance companies require these to be billed, but often do not reimburse for this service leaving the member responsible for payment.
Conditions of Use for Emails: Emails can be an effective form of communication. I will make every effort to maintain security and confidentiality of the email information received and sent, but cannot guarantee security. The provider is not liable for improper disclosure of confidential information that is not caused by the provider’s intentional misconduct. Please acknowledge the following 1) Email is not an appropriate way to communicate urgent/emergent situations. 2) Emails should be concise and the patient/guardian should schedule an appointment to discuss clinical issues. 3) Emails may be printed and filed with the medical record 4) Emails will not be forwarded to other providers without the patient’s written consent, except as authorized or required by law 5) Sensitive medical information should not be communicated through email. 6) Provider is not responsible for breaches of confidentiality caused by the patient or any third party.
FEES FOR SERVICE
This practice does have contracts with most commercial/private insurance companies and Medicaid HMO, and Medicare. Claims are submitted to the insurance companies and every effort is made to collect according to your individual benefit plan, however, it is your responsibility to make sure the office has the most current, up to date and accurate information. Please make sure to read your individual plan benefits for mental health services. Some plans may have limitations to the frequency of covered visits, as well as types of medications covered. If you have questions about your plan, please call your plan administrator.
Insurance companies do require the practice/provider to allow the insurance company to provide them with clinical diagnoses. Occasionally, additional information such as most recent encounter notes and treatment plans are requested for certain forms of treatment, additional sessions, or medication approval (prior authorization). Once information is provided, the insurance company is subject to privacy policies regarding your health information.
Additional Charges for Services
Some services requested require billing, but are not reimbursed by insurance and the individual may be fully responsible for payment. Examples include:
Legal depositions/contact with attorneys
Writing of reports or filling out forms
Short Term Disability - $75.00
Long Term Disability - $75.00
Emotional Support/Service Animal - $75.00
Returned phone calls for longer than 10 minutes in duration, and excessive phone calls
Returned checks (fee of $50) and fees associated with collections
Fees/Costs for Self-Pay (No Insurance):
Initial Intake: $275.00
15 - 29 Minute Encounter: $100 Follow-Up
30 - 50 Minute Encounter: $125
60 Minute Encounter: $175.00
Form Completion: (Letters to Schools/Work, Accommodations, Short/Long Term Disability, Emotional/Service Animal, etc).:
10 - 15 minutes: $75
16-30 minutes $150
>30+ minutes: $200
Texting/Emailing/Calls Outside Appointment Times:
Totaling 10-15 minutes: $75
Contact with attorneys
** These are the prices for out of pocket/cash paying clients. Fees with insurance companies are negotiated by individual contract.
** If fee schedule changes you will be provided at least a 30-day notice
Billing and Payments
Payment is due in full at the time of service, unless you are covered by one of the carriers contracted. Insurance copays, deductibles, and non-covered expenses are due on the day of the appointment. You will be asked to pay any outstanding balances prior to being seen, unless an alternative financial arrangement have been made.
If no insurance benefits are provided at the time of service, you will be asked to pay for the service before the visit starts.
All payments should be made to Farrah Thornsberry, Psychiatric & Mental Health Services. You can pay with cash or debit/credit card. Any delinquent account greater than 90 days may be sent to collections.
PROFESSIONAL RECORDS & CONFIDENTIALITY
Both law and professional standards require providers to keep accurate and appropriate treatment records, as well as ensure the protection and privacy of your mental health information. Health information is only disclosed to carry out treatment, obtain 3rd party payment and to discuss with another provider with your consent. You are entitled to review your records. I suggest that we do this together to ensure information is understood and not misinterpreted. Time spent collecting, printing, copying, and summarizing the record will be charged a fee.
Confidentiality is the cornerstone of mental health treatment and is protected by law. The sensitivity of your information is important to me, so any disclosure of your treatment to others will require your written consent.
The confidentiality of all communications is governed by both Federal and State laws. Exceptions to the confidentiality rule are:
Danger to Others – if there is a threat to the safety of others, I am required by law to take protective measures, including reporting the threat to the potential victim, notifying the police, and seeking hospitalization.
Danger to Self – if there is a threat to yourself, I am required to seek immediate hospitalization, and will likely seek the aid of family members or friends to ensure your safety. Danger to self may include suicidal threats, but may also include that your mental illness is preventing you from providing for your own basic needs such as food, water, shelter.
Court Order/Legal Hearings – you do have the right to refuse my involvement in hearings. There are rare situations, however, in which I am required by a judge to testify on your emotional, or cognitive condition.
Evidence of Child or Elder Abuse
I block two hours for the initial psychiatric evaluation. There is a lot of information gathered during this initial encounter to help me get a comprehensive assessment and focuses on developing the best treatment plan for your individual needs. Not all initial evaluations take the full two hours, but it allows us time to not feel rushed or pressured to finish when we prepare and allot for this amount of time. Please complete additional forms prior to initial visit to help ensure we have complete history. This information will include previous providers, past psychiatric treatment, past medication trials, developmental/education history, medical history, and family medical/psychiatric histories. Collateral information is often necessary for children/adolescents, as well as some adult patients, which includes school reports, family reports, and possibly medical record requests.
Follow-up/Medication Management Appointments
If we start a new medication, the appointments will be scheduled every week or two, which allows us an opportunity to evaluate medication effectiveness, tolerability and dose adjust towards therapeutic levels.
Depending on how the individual is doing and the level of complexity, determines the amount of time spent in the appointment. Most medication management appointments are 20 – 30 minutes. However, if the appointment also incorporates therapy in the visit, the duration could last up to 60-minutes.
Therapy appointments are scheduled for 60-minute intervals.
Cancellations and No-Show Policy
If you must cancel or reschedule your appointment, I require no less than 24-hour notice (weekends not included). If your appointment is on Monday, then cancellation must be made the preceding Friday. Cancellations that occur with less than 24-hour notice or no-shows will be charged $125.00. Often there is a waitlist for appointments, so it is important to keep your scheduled appointments or cancel with appropriate notice to allow someone else time to be notified about the opening. If you have 2 or more late cancelations or no-shows in a 12-month period, then you may risk not being rescheduled future appointments.
***Please note that if you arrive later than 10 minutes past your appointment time, you may be asked to reschedule.
Medications will only be filled for patients who maintain their regularly scheduled appointments and are in good standing. Prescriptions will be written at each appointment. If you do need a refill in between appointments, a prescription may be written to cover you until your next scheduled appointment. Please allow for up to 72 hours (not including weekends/holidays/vacations). Controlled substances can only be written for 30 days at a time, examples of this type of medication includes Adderall, Vyvanse, Focalin, Xanax, Modafinil, Ativan, Xanax, Ambien, etc. There will never be a refill on any of these medications. This is a law and there are no exceptions. Please make sure to keep these medications locked up and in a safe place. Early refills are not permitted, pharmacies will not fill them. If you lose your controlled substance or it gets stolen you will have to wait until the 30-day refill.
Termination of Treatment
Both the patient and provider maintain the right to terminate treatment. Reasons that a provider result in termination of treatment from the practice by the provider include, not limited to:
Lack of treatment adherence
Late cancellations or no-shows
Noncompliance with appointments
Misusing prescribed medication
CONSENT TO TREAT
Your electronic signature indicates that you have read the Treatment Consent and Practice Guidelines, which includes
Services Offered (Psychiatric Evaluation, Medication Management, Psychotherapy)
Contacting the Office/Provider (Office Hours, After Hours, Email Correspondence)
Fee for Service (Insurance, Additional Charges, Fees/Costs, Billing & Payments)
Professional Records (Medical Records, Confidentiality)
Appointments (Initial Visit, Follow-Ups/Medication Management, Therapy,
Cancellations & No-Shows, Prescriptions/Refill Requests, Termination of Treatment)