New Patient Paperwork

New Patient Paperwork

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Patient Financial Agreement
The management of mental health-benefits has become very complex and time consuming. We try to be accurate when informing you of your benefits, but as insurance companies clearly state, “benefit information is not a guarantee of payment.” Therefore, we cannot be certain of your account balance until after we receive payment from your insurance company.
I have read and understand this agreement.
INSURANCE:
 You are responsible for knowing whether your insurance covers the services of the provider you are seeing. To contact your insurance company about this, use the customer-service numbers on your insurance card, or ask your employer.

 Insurance policies are contracts between you and your insurance company. We file claims as a courtesy, but you are responsible for issues beyond our control. If your insurance does not pay within a reasonable time, you will be responsible for the full payment.

 We will file your secondary insurance as a courtesy. However, you will be responsible for what your primary insurance does not cover and/or what your secondary insurance does not pay in a timely manner.

 If your provider is not covered by your insurance company, payments are due in full when services are provided.

 We will only retroactively file Medicaid charges six months from the date you give us your Medicaid card.

Balances:
 If your balance is over 30 days past due, ask to speak to the patient account coordinator.

 Any account with a balance that has not received a payment in 90 days will have their account placed on hold from scheduling any further appointments.

 If a payment plan has been set up and you have missed a payment on two occasions, this will be cause for an automatic dismissal.

Co-Payments:
 Co-payments are due at the time of service. This is the total of what the insurance does not pay. If co-payments are not made, we may be unable to continue to provide services.

No Shows/Late Cancellations:
 There are charges for missed appointments and late cancellations, which are any appointments cancelled less than 24 hours prior to the appointment’s start time. These fees can range from $65-$100 depending on the length and type of appointment.

 Patients are responsible for their appointments. Reminder calls are a courtesy. Cancellations within 24 hours and no-shows may be charged for, and you will be responsible for the charge.

Additional Charges:
 Charges for phone consultations may not be covered by insurance. Phone consultations are defined as phone calls made to/from the patient’s doctor or the doctor-on-call outside of a scheduled appointment and/or office hours.

 Prescriptions and refills are charged $20-$30 per prescription written, called in, or faxed, outside of a scheduled appointment.

 Contact initiated through the patient portal which requires review by the care provider for care management, and may include the ordering of prescriptions, tests, or further care coordination, may be considered a billable service. If your insurance is billed, you will be responsible for your co-pay/deductible for this communication.

 Office visits with the psychiatric nurse will be filed with your insurance, and you may be responsible for your copay, depending on your plan.

Notice of Privacy Practices Acknowledgement
I have been offered a copy of The Pisgah Institute's Notice of Privacy Practices.*
I agree to the privacy policy.
The Pisgah Institute for Psychotherapy and Education, P.A.

Notice of Privacy Practices

AS REQUIRED BY THE PRIVACY REGULATIONS CREATED AS A RESULT OF THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 (HIPAA) AND THE HEALTH INFORMATION TECHNOLOGY FOR ECONOMIC AND CLINICAL HEALTH ACT OF 2009 (HITECH). UPDATED AUGUST 1, 2017.

PLEASE REVIEW THIS INFORMATION CAREFULLY.

A. WE ARE COMMITTED TO YOUR PRIVACY:

Our practice is dedicated to maintaining the privacy of your Protected Health Information (PHI). In conducting our business, we will create records regarding you and the treatment and other services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We are also required by law to provide you with this notice of our legal duties and the privacy that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

• How we may use and disclose your PHI
• Your privacy rights about your PHI
• Our obligations concerning the use and disclosure of your PHI

The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revisions or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current notice in our offices in a visible location at all times, and you may request a copy of this notice at any time.

B. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

Bill Barley, Ph.D.
158 Zillicoa Street
Asheville, NC 28801
828/254-9494

C. WE MAY DISCLOSE YOUR PROTECTED HEALTH INFORMATION IN THE FOLLOWING WAYS:

1. Treatment. Our practice may use your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood or urine tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice—including but not limited to our clinicians—may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may disclose your PHI to other health-care providers for purposes related to your treatment. You must authorize use and disclosure of our clinicians’ private “psychotherapy notes” in most cases, except when such use or disclosure is required by law.

2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and for what range of benefits, and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other health-care providers and entities to assist in their billing and collection efforts.

3. Health-Care Operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you receive from us, or to conduct cost-management and business-planning activities for our practice. We may disclose your PHI to other health-care providers and entities to assist in their health-care operations. Uses and disclosures of your PHI for marketing purposes require your authorization. Sale of your PHI requires your authorization, except when required by law or for remuneration for treatment.

4. Appointment Reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.

5. Email Correspondence. Our practice cannot guarantee security of any information we send to or receive from you via email, and we do not use it for that purpose.

6. Release of Information to Family or Friends. Our practice may release your PHI to a friend or family member who is involved in your care or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter take their child to our office for a treatment session. In this example, the babysitter may have access to this child’s PHI.

7. Disclosures Required by Law. Our practice will use and disclose your PHI when we are required to do so by federal, state, or local law.

8. Other Uses and Disclosures. Other uses and disclosures not described in this Notice of Privacy Practices require your authorization.

D. YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED WITHOUT YOUR SPECIFIC AUTHORIZATION IN CERTAIN SPECIAL CIRCUMSTANCES:

1. Public-Health Records. Our practice may disclose your PHI to public-health authorities that are authorized by law to collect information for the purpose of:

• Maintaining vital records, such as births and deaths
• Reporting child abuse or neglect
• Preventing or controlling disease, injury, or disability
• Notifying a person regarding potential exposure to a communicable disease or condition
• Notifying a person regarding a potential risk for spreading or contracting a disease or condition
• Reporting reactions to drugs or problems with products or devices
• Notifying individuals if a product or device they may be using has been recalled
• Notifying appropriate government agency(ies) and authority(ies) regarding the potential abuse or neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information
• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance

2. Health-Oversight Activities. Our practice may disclose your PHI to a health-oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health-care system in general.

3. Lawsuits and Similar Proceedings. Our practice may use and disclose your PHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceedings. We also may disclose your PHI in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement. We may release PHI if asked to do so by law-enforcement official:

• Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement
• Concerning a death we believe has resulted from criminal conduct
• Regarding criminal conduct at our offices
• In response to a warrant, summons, court order, subpoena, or similar legal processes
• In an emergency, to report a crime (including the location or victim(s))

5. Research. Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) The use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health-research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which use or disclosure would otherwise be permitted. (ii) The research could not practicably be conducted without the waiver. And (iii) the research could not practicably be conducted without access to and use of the PHI.

6. Serious Threats to Health or Safety. Our practice may use or disclose your PHI when necessary to reduce or prevent a serious threat to your health or safety or to another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

7. Military. Our practice may disclose your PHI if you are a member of the U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

8. National Security. Our practice may disclose your PHI to federal official(s) for intelligence and national-security activities authorized by law. We may also disclose your PHI to federal officials in order to protect the President or other officials or foreign heads of state, or to conduct investigations.

9. Inmates. Our practice may disclose your PHI to correctional institutions or law-enforcement officials if you are an inmate or under the custody of a law-enforcement official. Disclosure for these purposes would be necessary: (i) for the institution to provide health care services to you, (ii) for the safety and security of the institution, and/or (iii) for the protection of your health and safety or the health and safety of other individuals.

10. Worker’s Compensation. Our practice may release your PHI for Worker’s Compensation and similar programs.

E. YOU HAVE RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION:

1. Confidential Communications. You have the right to request that our practice communicate with you about your health-related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to Bill Barley, Ph.D. or his designee specifying the requested method of contact or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

2. Requesting Restrictions. You have the right to request a restriction on our use or disclosure of your PHI for treatment, payment, or health-care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends, or that we do not disclose your PHI to them. We are not required to agree to your request; however if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. You may refuse us permission to share your PHI solely for the purpose of payment for a service or item for which you have already paid in full out of pocket. In order to request a restriction in our use or disclosure of your PHI, you much make your request in writing to Bill Barley, Ph.D or his designee. If you are contacted by or on behalf of our practice for fundraising purposes, you have a right to opt out of such communications on the occasion of any such solicitation.

Your request must describe in a clear and concise fashion:

 The information you wish restricted;
 Whether you are requesting to limit our practice’s use, disclosure, or both; and
 To whom you want the limits to apply.

3. Inspection and Copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records, but not including our clinicians’ private “psychotherapy notes.” You must submit your request in writing to Bill Barley, Ph.D. or his designee in order to inspect and/or obtain a copy of your PHI. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health-care professional chosen by us will conduct such reviews.

4. Amendment. You may ask us to amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing to Bill Barley, Ph.D. or his designee. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (i) accurate and complete; (ii) not part of the PHI kept by or for the practice; (iii) not part of the PHI which you would be permitted to inspect and copy; or (iv) not created by our practice, unless the individual or entity that created the information is not available to amend the information. Amending PHI means adding to it, not replacing it. Our practice may charge you for copying your PHI for you.

5. Accounting of Disclosures. All of our patients have the right to request an accounting of disclosures. An accounting of disclosures is a list of certain non-routine disclosures our practice has made of your PHI for non-treatment, non-payment, or non-health-care-operations purposes. Such would include unauthorized disclosures that do not rise to the level of a breach or disclosures that are in response to a subpoena supported by an affidavit of satisfactory assurances if the subpoena is deemed deficient by itself. Use of your PHI as a part of the routine patient care in our practice is not required to be documented (for example, a doctor sharing information with another clinician, or the billing department using your information to file your insurance claim). In order to obtain an accounting of disclosures, you must submit your request in writing to Bill Barley, Ph.D. or his designee. All requests for an accounting of disclosures must state a time period, which may not be longer than six years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs. You will be notified by our practice of any breach of your PHI, in accordance with HIPAA and HITECH definitions and rules.

6. Right to a Paper Copy Notice. You are entitled to receive a paper copy of our Notice of Privacy Practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, ask a staff member at the check-in or check-out window.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with our practice, contact Bill Barley, Ph.D. or his designee. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

8. Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked by you at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization. Please note that we are required to retain records for your care.

Again, if you have any questions regarding this notice or our privacy policies, please contact Bill Barley, Ph.D.
Notice of Release of Initial Assessment to Referring Clinician
I understand that if I have been referred to The Pisgah Institute by another health care provider, my initial evaluation will be sent to that referring provider upon completion. I have the right to prevent this disclosure of my Protected Health Information. ***Please indicate your preference by choosing ONE of the options below:
*
- I understand that this information will be disclosed to the referring provider.
- I DO NOT authorize the disclosure of this information.
Mental Health Authorization for Disclosure of Protected Health Information
Appointment and Prescription Consent
I authorize The Pisgah Institute and its employees to inform the following person of my appointment time(s). I understand that this information is revocable except to the extent that action has to be taken in reliance thereon, and this authorization shall remain in force for one year.*
Name Relationship to Patient
I authorize The Pisgah Institute and its employees to discuss prescription matters with the following person. I understand that this authorization is revocable except to the extent that action has been taken in reliance thereon, and this authorization shall remain in force for one year.*
Name Relationship to Patient
Informed Consent
Informed Consent for Treatment and Services*
I have fully read the informed consent document.
Informed Consent

Welcome to The Pisgah Institute! We are licensed by the State of North Carolina as physicians, psychologists, psychiatric nurse practitioners, and physician assistants. We provide medication le for this management and individual, couples, family, and group psychotherapy. We also provide psychological testing and transcranial magnetic stimulation.

This document contains important information about professional services and business policies at The Pisgah Institute. Please read it carefully and jot down any questions you might have so that we can discuss them at our next meeting. When you sign this document, it will represent an agreement between us.

What to Expect From Treatment

Seeking help might not be an easy thing to do. Your needs are not like everybody else’s. During your initial appointment, your clinician will evaluate your current situation, problems, and symptoms. You may be asked questions about your personal, family, and health background, as well. Toward the end of your first appointment, you will discuss a tentative treatment plan for going forward.

Some patients will need only a few appointments to reach their goals and feel and do better. Other people may need many treatment sessions. Sometimes people feel worse before they progress and feel better. Psychiatric and psychological treatment is an active process, the more successful the more actively engaged you are with it. That means coming on time and regularly to your appointments. Many patients note improved feeling and functioning, including improved relationships, after they have participated in treatment. However, it is impossible to provide such guarantees. You are the consumer of these services, and your input to and about them is very important, including about when you no longer need them.

It is important that the clinician – psychiatrist, clinical psychologist, psychiatric mental health nurse practitioner, or certified physician assistant — you are meeting with is a good fit for you. If you have questions or concerns, we encourage you to first speak with her or him. If you determine a change of provider is needed, you may call the office to request a change. We will do our best to assist in referring you to another qualified provider, whether within our practice or elsewhere.

Appointment Policies

To cancel or reschedule an appointment you must provide 24-hour advance notice. If you do not provide 24-hour notice or do not show for your appointment, you will be responsible for the no-show or late cancel fee according to the Patient Financial Agreement. You will be responsible for this charge; it cannot be billed to your insurance company. Our appointment reminders are sent as a courtesy; you will be responsible for charges for missed appointments whether or not a reminder is sent.

In the event of inclement weather, your safety is of utmost importance. Therefore, we do not charge a late cancellation fee for in-person appointments to which you feel it is unsafe to drive due to road conditions. Your provider may be able to offer other arraignments, such as telehealth, to ensure your access to care despite inclement weather.

An excessive number of late-cancelled or no-show appointments, as judged by your clinician, as well as nonpayment of your account, can result in dismissal from the practice. The final decision is each clinician’s. If you are dismissed, it is unlikely you will be reassigned to another provider in our practice.

Confidentiality

With few exceptions, your personal information will be held in confidence. In some situations, we may need to release some kinds of personal information to secure needed professional services for you, obtain appropriate professional consultations, protect you and/or others from harm, or obtain payment for services. We follow federal and state laws as well as professional ethical guidelines when handling confidential information. We will disclose confidential information when you have given us written consent to do so, when the law mandates the disclosure, and/or when the law gives us the discretion to disclose. Limitations of confidentiality exist and are listed below:

1. If a clinician believes you intend to harm yourself or another person.
2. If a clinician has a reasonable suspicion that a patient or other named victim is the perpetrator, observer of, or actual victim of physical, emotional, or sexual abuse of children.
3. If a clinician has reasonable suspicion that a child, elderly person, or disabled person is being or has been abused or neglected.

This summary of exceptions to confidentiality is intended to inform you about potential issues that could and it is important that we discuss any questions or concerns that you may have about these matters at our next meeting. Your clinician will be happy to discuss these issues with you and provide clarification when possible.

Emergencies

If you find yourself in urgent need of an appointment, please call us to see when and how we may accommodate you. We will do our best to respond quickly to your needs, but please note that immediate appointments may not always be available.

If you have an unusual physical or emotional reaction to your medications or have suicidal or homicidal thoughts, please call the office to talk to your clinician or the clinician on call. After hours, you can reach the clinician on call through our general number (828-254-9494) and answering service.

Financial Policy

If you have a health-insurance policy, it will usually provide some coverage for mental-health treatment. The Pisgah Institute will provide you with whatever assistance we can to help you receive the benefits to which you are entitled. However, you, not your insurance company, are responsible for full payment of fees. It is very important that you find out exactly what mental-health services your insurance policy covers. An estimate of the expected annual cost for treatment is available to you upon request.

You should also be aware that most insurance companies require that we provide them with your clinical diagnosis. Sometimes we have to provide additional clinical information, such as treatment plans, progress notes or summaries, or, in rare cases, copies of the entire record. This information will become part of the insurance company’s files. Though all insurance companies claim to keep such information confidential, your clinician and this practice have no control over what they do with it once it is in their hands. In some cases, they may share the information with a national medical information databank. Your clinician will provide you with a copy of any records we disclose, if you request it.
You understand that, by using your insurance, you authorize The Pisgah Institute to release otherwise confidential information to your insurance company. We will try to keep that information limited to the minimum necessary.

Authorization and Consent for Treatment

I hereby grant my authorization and consent to treatment and procedures deemed appropriate and certify that no guarantee or assurance has been made as to the results which may be obtained. I understand that I also have the right to refuse treatment by not signing here and that refusal of consent shall not be used as the sole grounds for termination or threat of termination of service unless the procedure is the only viable treatment or habilitation option at our facility, according to NCG S 122C-57. I further understand that I have a right to treatment, including access to medical care and habilitation, regardless of age or degree of mental-health/intellectual developmental disability/substance abuse disability, under G S 122C-51. Further, I give authorization for The Pisgah Institute to seek emergency medical care on my behalf from a physician or a hospital in case of an emergency.

Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.
Name of Consenting Individual
Date of Consent
Month
Day
Year
Signature