AutoPsych Terms, conditions, privacy and telehealth agreement. This document contains important information about professional services and business policies. Please read it carefully. Once you sign this document, it will constitute a binding agreement between us. This company does not accept insurance. It is the policy to have clients complete and monitor their own, if any, insurance claims. It is the client’s responsibility to discuss with their insurance company how to file said claim. The amount of reimbursement from the insurance company will depend upon the insurance policy. Payment Policy. Payment is due in full before the time of service. If you fail to present for 2 appointments or have not completed a consultation in a 3 month time period, no medications will be refilled until you schedule an appointment and a care consultation has been completed. If you fail to complete consults per recommendations from our provider team, you may be terminated from this membership agreement, and a letter will be emailed to you to this effect. Contacting Information. You may contact us using our secure online system, texting or calling our main number, or emailing us at hello@autopsych.com. Emails are usually checked by non clinical staff once daily from 12-1p CST. Responses may take up 3 business days. If your message has not been returned within the time frame outlined above, please send your message again. In the event of an emergency please call 911 or present to your nearest emergency department. Refills Medication refills require regular consultation for safe monitoring. You will be required to complete consultations regularly to continue treatment. Prescriptions will not be refilled if consultations are not completed, so please be prepared to complete these as recommended, usually at least once every 3 months. Scheduling Appointments. LIVE, real time scheduled visits can be scheduled any time online at www.autopsych.com. If you need to reschedule, please do so online at www.autopsych.com. All LIVE, real time visits are conducted using a secure web-based, face-to-face video conference system. At the time of scheduling your appointment, we will obtain appropriate financial information from you for billing, including current billing address and credit card number. Automated appointment reminders will be sent to you electronically to remind you of your upcoming appointments. And you can schedule appointments online any time. Appointments are billed automatically with your account information on file the week before your appointment. We will do everything possible to be sure you are seen promptly. Confidentiality. Confidentiality is strictly observed. In general, the law protects the confidentiality of all communications between a patient and their provider, and we can only release information about our work to others with your written permission. However, there are a number of exceptions. In most judicial proceedings, you have the right to prevent us from providing any information about your treatment. However, in some circumstances such as child custody proceedings and proceedings in which your emotional condition is an important element, a judge may require my testimony if he/she determines that resolution of the issues before him/her demands it. There are some situations in which we are legally required to take action to protect others from harm, even though that requires revealing some information about a patient’s treatment. For example, if we believe that a child, an elderly person, or a disabled person is being abused, we are legally mandated to file a report with the appropriate state agency. If we believe that a patient is threatening serious bodily harm to another, we are (maybe) required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization. If a patient threatens to harm himself/herself, we are required to seek hospitalization for the patient, or to contact family members or others who can help provide protection. We may occasionally find it helpful to consult about a case with other professionals. In these consultations, we make every effort to avoid revealing the identity of the patient. The consultant is, of course, also legally bound to keep the information confidential. Unless you object, we will not tell you about these consultations unless we feel that it is important to our work together. While this written summary of exceptions to confidentiality should prove helpful in informing you about potential problems, it is important that we discuss any questions or concerns, which you may have at our next meeting. The laws governing these issues are quite complex, and we are happy to discuss these issues with you. Should you need specific advice, formal legal consultation may be desirable. Worker’s Comp. We do not provide services regarding Workers Comp Injuries. Please contact your employer for instructions about these types of requests. Professional Records. Both law and the standards of practice require that we keep appropriate treatment records. You are entitled to receive a copy of the records, unless your provider believes that seeing them would be emotionally damaging, in which case, we will be happy to provide them to an appropriate mental health professional of your choice. Because these are professional records, they may be misinterpreted and/or can be upsetting, so we recommend that we review them together so that we can discuss what they contain. Patients will be charged an appropriate fee for any preparation time, which is required to comply with an information request. Treatment setting. All assessments and treatments are conducted via secure telehealth or by using our secure automated follow up and initial automated assessment system in direct collaboration with our provider team. This may include your doctor, nurse, therapist, physician assistant, or other Autopsych treatment team member. Treatment services will focus on the assessment and treatment of medical conditions as they relate to impaired focus, emotional regulation, and sleep. The use of secure, and confidential telemedicine services using a HIPAA compliant secure video conferencing system, will be implemented to conduct assessments and direct treatment recommendations when appropriate. Use of secure video conferencing will constitute face-to-face meetings for visits. Every client will be responsible to regularly assess and provide accurate weight, blood pressure, and heart rate measurements throughout the duration of care to assist with safe medication monitoring and to meet widely accepted standards of care. Every client may be subject to formal laboratory testing as per the directions from their treating provider for the purpose of verifying medication compliance and ensuring safe medical practice. Clients receiving pharmacological care and management with AutoPsych are required to maintain treatment with a single prescribing provider team throughout their duration of care. Receiving multiple prescriptions, for the same or dangerously similar medications from multiple providers at the same time is strictly prohibited. Failure to abide by this agreement will result in termination of this care agreement. Compliance with this requirement will be monitored regularly using appropriate and accepted prescription drug monitoring programs. Your signature indicates that you have read the information in this document, understand all that it contains, and agree to abide by its terms during this professional relationship. Subscription service. Subscription to our professional care service, AutoPsych, includes regular consultations and regular medication refills at no additional cost. This is designed to help clients improve over the course of time. This service is not designed for those with severe mental illness or SMI, including psychotic disorders, bipolar disorders, and substance use disorders. All subscribers that experience a severe mental illness will be directed to the appropriate service entity to obtain the most appropriate level of care for their condition. Assessments are designed to screen and monitor for the symptoms that may suggest the presence of a severe mental illness. Subscription services require us to save your payment information securely using our automated payment system. Fees will be obtained automatically every 30 days or every year based on your preferred payment schedule. If the payment is denied, you will be informed immediately, and services will be discontinued until payment is received. Your subscription will be resumed only with receipt of payment and by agreement to resume care by your treatment team. Services not included in our subscription service include special document processing, medical records requests, psychotherapy services, lab services, general medical services, extra prescription services, and additional care visits or services outside routine and provider recommended care unless otherwise specified by AutoPsych. There will be an additional fee for live follow up visits scheduled to be conducted with one of our providers. Live visits are scheduled by selecting a preferred time and completing payment online at time of booking. Booking can be done any time on our website at www.autopsych.com. Safe and appropriate use of these services is guided and monitored regularly for each client by the provider team, which includes our licensed providers, physicians, and practitioners. Subscriptions can be discontinued or resumed at any time, and we reserve the right to discontinue subscriptions at any time for any reason. Emergency support services will be offered for 30 days from the date of discontinuation, and the client will be informed of this in writing. Subscription services will be offered only to established clients that have completed a live and in-person evaluation with our team or one of our affiliated providers. PRIVACY NOTICE THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The privacy of your medical information is very important to us. You may be aware that U.S. government regulators established a privacy rule (HIPAA) governing protected health information. This notice tells you about how it may be used, and about certain rights that you have. Your provider is in charge of privacy matters at this office. You may contact the clinic if you desire further information or have any questions or concerns. Use and disclosure of Protected Information Federal law provides that we may use your medical information (protected health information or PHI) for treatment of you without further specific notice to you, or written authorization. Such as, if we refer to a specialist, we may provide copies of treatment history or x-rays or other lab tests or diagnostics to that specialist. Federal law provides that we may use your medical information to obtain payment for our services without further specific notice to you, or written authorization by you. For example: our accountants may see your name, dates of treatment, and procedure codes during audits of our books. Your name may also be used for financial services, quality assurance, risk reduction, and claim management purposes with our medical professional insurer. We may use or disclose your medical information, without further notice to you, or specific authorization by you, where: 1. Required by law 2. Required for public health purposes 3. Required by law to report child abuse 4. Where required by a health oversight agency for oversight activities authorized by law, such as the Department of Health, Office of professional Discipline, or Office of Professional Medical Conduct 5. Required by law in judicial or administrative proceedings 6. Required for law enforcement purposes by a law enforcement official 7. Required by a coroner or medical examiner 8. Permitted by law to a funeral director 9. Permitted by law for organ donation purposes 10. Permitted by law to avert a serious threat to health or safety 11. Permitted by law and required by military authorities if you are a member of the armed forces of the United States We may contact you by mail, personal email, or phone at your residence to remind you of appointments, help with scheduling, or to provide information about treatment alternatives. Unless you instruct us otherwise, we may leave a message for you on an answering device or with any person who answers the phone at our residence. You can make reasonable requests, in writing, for us to use alternative methods of communicating with you in a confidential manner. Other uses or disclosures of your medical information will be made only with your written authorization. You have the right to revoke any written authorization that you give and do so in writing. Rights that you have You have the right to request restrictions on certain uses or disclosures described above. Except as stated below, we are not required to agree to such restrictions. You have the right to request amendments to your medical information. Such requests must be in writing and must state the reason for the requested amendment. We will notify you as to whether we agree or disagree with the requested amendment. If we disagree with any requested amendment, we will further notify you of your rights. You have the right to request an accounting of any disclosures we make of your medical information, except for: disclosures we make to you, or carry out treatment, payment or health care operations, or as requested by your written authorization or as permitted or required under 45CFR § 164.502, or for emergency or notification purposes, or for national security or intelligence purposes as permitted by law, or to correctional facilities or law enforcement officials as permitted by law (or for research or public health purposes after being de-identified or limited to remove personally identifiable information) or disclosures made before April 14, 2003. If you have received this notice electronically, you have the right to obtain a paper copy from our office. Obligations that we have. We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices. We are required to abide by the terms of this notice as long as it is currently in effect. We reserve the right to revise this notice, and to make a new notice effective for all protected health information we maintain. Any revised notice will be posted. If you want to complain about violations of your privacy rights, you have the right to file a complaint with the Secretary of the Department of Health and Human Services of the United States. You may also file a complaint with us. Complaints should be directed to your provider using your secure patient portal. No retaliatory action will be taken against you for any complaint you may make. By signing this form, you acknowledge that your provider with us has given you a copy of their provider notice. This must be signed prior to or on your first date of service with your provider. I have received a copy of this notice. I agree to utilize Doxy.me or other similar HIPAA compliant telemedicine services for conducting secure telemedicine services for clinical visits. PATIENT CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION. I hereby state that by signing this consent, I acknowledge and agree as follows: 1) This office’s privacy notice has been provided to me prior to my signing this consent. The privacy notice includes a complete description of how the office uses or discloses my protected health information(PHI). This office has stated that this notice is available to me in the future at my request, and I have the right to obtain a copy for my records. 2) The office reserves the right to change its privacy practices that are described in its privacy notice, provided it is permitted by law. 3) I understand and authorize the following appointment reminders that will be used by this office:a) Secure patient portal messages to a patient provided cell phone contact number. b) Secure patient portal messages to a patient provided private email account. 7) I understand that I have the right to request that the office restrict how my PHI is used and/or disclosed to carry out treatment, payment and/or health care operations. However, the office is not required to agree to any restrictions that I have requested. If the office agrees to a requested restriction, then the restriction is binding on the office. 8) I understand that this consent is valid for seven years. I further understand that I have the right to revoke this consent, in writing, at any time for all future transactions. If I do not sign this consent, they may decline to provide treatment to me. INFORMED CONSENT. I hereby acknowledge that I understand the services offered to me by AutoPsych, including the use of technology based communications and information gathering tools to request and receive care that is provided by providers associated with AutoPsych. I also understand that this care can be discontinued any time, and that a referral to other care providers may be offered. My signature below also indicates that I hereby document my consent to receive these services and that the services to be provided have been fully disclosed to me, and I am fully competent to receive these services. CONSENT FOR FINANCIAL RESPONSIBILITY. Thank you for choosing AutoPsych. We are fully committed to your success. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our Financial and Policy Fees, which we require that you sign before receiving treatment. Understand and acknowledge that you are m responsible for payment of all services rendered in this office including any charges for missed appointments as outlined below. You understand that payment is expected before the time of service by credit, debit card, or electronic transfer. You consent to a credit card number being stored in your file for charges such as missed appointments, telephone calls, physician’s statements, etc. You understand that this is a relationship with an out-of-network provider, and that it is your responsibility to determine what, if any, reimbursement you will receive from an insurance company. Any insurance claims are the responsibility of the client. You also understand that it is your responsibility to discuss with your insurance company how to file said claim. You are responsible for payment for services rendered regardless of any determination made by an insurance company. Payment is required before time of service and will be charged the week before each appointment. Billing information, such as credit or debit card information will be saved and used for payment. If payment is rejected, your appointment will be canceled and you will need to reschedule for another available appointment time. Professional Fees can vary based on provider availability: AutoPsych Membership Enrollment Fee: $299.99. This may vary based on location and provider availability. Then, monthly Subscription AutoPsych Service Fee: $99.99. Requested Form/Document/Record Completion $25* LIVE, real time follow up consults for members: $99.99. *Documentation to be completed as per provider approval and discretion Fees for services may be adjusted at any time by AutoPsych. You understand that it is the policy of AutoPsych to charge in full for any appointments missed or canceled. All fees are nonrefundable. To ensure safe continuity of care, if a medication refill request period, usually 30 days, overlaps with your next consult, you will need to complete that consultation before a 30 day supply can be provided. This helps our team monitor your care response and ensure safe continued use. Clients may request missed appointments to be rescheduled only at the discretion of AutoPsych. Clients requesting provider’s services by telephone, a provider’s statement, typed copy of the evaluation, or transfer of medical records, should be aware that there is an additional charge for such services. Your signature verifies that you have read and understand your financial responsibility and you agree to all of the terms, policies and consents as stated above.