Policy Form

 

This form is a comprehensive agreement and consent document for patients receiving care at Eagle View Psychiatry. It outlines several important policies and consents, including:

  1. Insurance and Financial Agreement: Authorizes the release of information to insurance providers for claim processing, explains patient responsibilities for pre-authorization and payment of services, and details fees for missed appointments and paperwork requests.

  2. Medical Treatment Authorization: Grants permission for Eagle View Psychiatry to provide necessary treatments and release medical records as needed.

  3. Patient Information: Specifies office hours, cancellation policies, prescription refill procedures, and termination policies.

  4. Telehealth and Therapy Consents: Provides consent for telehealth services, details potential risks, and sets conditions for confidentiality and HIPAA compliance in therapy sessions.

  5. Medication Consent: Confirms the patient’s understanding of their prescribed medications, potential side effects, and responsibilities regarding the use of controlled substances.

Patients must review and sign the document to acknowledge their understanding and agreement with the terms and policies set by Eagle View Psychiatry.

Please enable JavaScript in your browser to complete this form.

Policy 1

INSURANCE RELEASE OF INFORMATION / ASSIGNMENT OF BENEFITS:


I authorize Eagle View Psychiatry to disclose any necessary medical information to my Medicare/Medicaid provider or the insurance carrier currently managing my coverage, for the purpose of authorization or payment for this and related claims. I also consent to direct payments being made to this office for the mental health benefits I receive. I understand that I am responsible for obtaining any required pre-authorizations from my insurance. Additionally, I acknowledge that I am financially liable for all charges incurred from services provided, regardless of whether my insurance company covers them.

FINANCIAL AGREEMENT

Pre-Authorization for Mental Health Services:

Many insurance providers require pre-authorization for mental health services. We strongly recommend contacting your insurance company to verify any pre-authorization requirements. Additionally, it’s advisable to review your mental health benefits as they may differ from general healthcare benefits. We do not manage your insurance plan and cannot provide specific details on how your coverage is applied. Please contact our billing department if you have questions regarding your insurance information.

Payment for Services:

Patients are expected to pay all co-pays, co-insurance, cost-sharing, and any outstanding balances at the time of service. For telehealth appointments, payment must be made the day before the session or on the preceding Friday if the due date falls on a weekend. If payment is not received, a statement will be issued, and the balance must be paid within 10 days. If you are unable to make a payment by the due date, please reach out to our Billing Department to discuss a payment plan. Any balances that remain unpaid for over 90 days will be sent to collections. Please inform us immediately of any changes to your address to avoid any delays in receiving statements.

Insurance:

Eagle View Psychiatry will submit insurance claims on your behalf. However, you are responsible for all pre-authorization, claim follow-up, and any charges not covered by your insurance. As the policyholder, it is your responsibility to inform us of any changes in your coverage, including secondary insurance plans. We do not manage your insurance plan, so it is up to you to understand your benefits and how they apply. Failure to update us on insurance changes may delay claim submissions, leading to patient liability. Insurance claims must be filed within specific timeframes, and delayed claims may result in patient bills. Contact your insurance provider to understand the coverage details before receiving your first explanation of benefits. If you do not receive an explanation of benefits within 30 days, follow up with your insurance company and inform our billing department at 916-999-1418 . Eagle View Psychiatry reserves the right to charge the full amount of the visit if there is no response from the insurance company within 45 days of claim submission. For questions regarding your account or insurance claims, please call 916-999-1418 for assistance.

Appointment No-Show Fee & Grace Periods:

By signing this form, I acknowledge that a 48-business-hour notice is required for all appointment cancellations. For example, if you have a Monday appointment, you must cancel by Thursday to avoid a fee. We offer a grace period of 15 minutes for in-person therapy appointments and 10 minutes for in-person practitioner appointments. Telehealth appointments have a 5-minute grace period. If you do not check in within this grace period, you will need to reschedule and will be billed. The no-show fee is $50 for the  missed appointment if not canceled within the required timeframe or if the patient does not attend.

Telehealth Notice & Disclosure:

For telehealth services, ensure all your contact information is current and that you are available at the scheduled appointment time. A 5-minute grace period is allowed for telehealth visits. If you cannot connect within this period, a missed appointment fee will apply, and you will need to reschedule. If you do not receive outreach within the first 3 minutes of your appointment time, contact our office immediately at 916-999-1418.

Private Pay Fees:

Initial Visit: $175
Follow-up Visit: $125

Acceptable Payment Methods:

Credit Card
HSA Accounts
Money Order
Check

Note: We do not accept cash. Returned checks will incur a $30 fee.

Paperwork Fees:

There are charges for completing and providing paperwork, letters, and medical records, including responses to disability, EDD, or Social Security forms. Work on document requests will only begin once payment is received. The fees are set based on the type of request and are non-negotiable and non-refundable, payable upon approval of the request. Document requests will only be processed after the completion of the initial intake and two follow-up appointments. The office is not responsible for any delays or issues with disability claims. Requests for medical records have a base fee plus an additional dispensing fee. For Work Comp. patients, paperwork charges will be billed to the insurance carrier.

I understand and agree to comply with the above Insurance Release of Information/Assignment of Benefits and the Financial Agreement.

Policy 2

Authorization for Medical Treatment, Statement of Responsibility, Acknowledgment of Privacy Practices, Patient Rights & Responsibilities, and Magellan Member Rights & Responsibilities

Authorization for Medical Treatment:

I give permission to the physicians, psychologists, therapists, their assistants, and/or designees involved in my care at Eagle View Psychiatry ("Facility") to administer any necessary or advisable treatments for my diagnosis and care. This includes, but is not limited to, routine diagnostic procedures, rehabilitation therapies, laboratory tests, and prescribed medications. I also authorize the release of copies of my medical records to other physicians and healthcare facilities as needed by my treating physician(s) or therapist(s). I understand that medicine is not an exact science, and no specific outcomes can be guaranteed for any examinations or treatments provided at this Facility. I acknowledge that my care is managed by my treating physician(s) and the Facility, and I agree to follow the instructions given by my physician(s) during my treatment.

Statement of Responsibility:

I understand that I am financially responsible for any charges not covered by the above assignments. This includes any medical insurance deductibles, co-insurance, or out-of-pocket expenses, whether I am the patient, parent, guardian, conservator, or the insured party.

Notice of Privacy Practices:

I have been given the opportunity to review Eagle View Psychiatry's Notice of Privacy Practices concerning Protected Health Information. I am aware that the Facility may change this Notice at any time, and I can obtain the most current version at the Facility's office during regular business hours.

Patient Rights & Responsibilities:

I have had the chance to review the Patient Rights & Responsibilities at Eagle View Psychiatry. I understand that these may be updated at any time, and I can get a current copy at the Facility's office during normal business hours. By signing below, I confirm that I have read and understood the above information and am either the patient, the patient's guardian, power of attorney, parent, or otherwise authorized to enter into this agreement and accept its terms.

Policy 3

IMPORTANT PATIENT INFORMATION

The providers and staff at Eagle View Psychiatry are committed to addressing your healthcare needs effectively. Please review the following policies and procedures:

Office Hours and Appointments:

Our office is open Monday through Sunday from 9 a.m. to 6 p.m. Providers are available for emergencies via email and chat on our website during business hours. For urgent assistance, please contact our call center at 916-999-1418. Follow-up appointments should be scheduled at the end of your visit or by calling 916-999-1418. If you need an emergency walk-in appointment, please be aware that delays may occur due to the unscheduled nature of such appointments. We appreciate your understanding and will do our best to address your needs promptly.

Cancellations:

To avoid a fee, please cancel your appointment at least 48 business hours in advance (e.g., cancel by Monday for a Wednesday appointment). We will be happy to reschedule your visit.

Paperwork:

We charge for the completion and processing of paperwork, letters, and medical records, including responses to Disability, EDD, or Social Security forms. We are not responsible for any loss of income or benefits due to delays with your claims. You are responsible for ensuring that your claim remains active and current.
  • Document service requests can be submitted by fax to 916-288-8886
  • Document processing will begin only after you have completed three appointments with our clinic.
  • Processing will only start if the provider agrees to the service request.
  • Processing will only commence after the full fee is paid.
Fees range from $125 to $175, depending on the request, and are non-negotiable and non-refundable. Document requests are processed upon approval and may take 7-14 days.
  • Medical records incur a fee upon approval, plus dispensing fee.
  • Record requests can be submitted by fax to 916 288 8886


Prescription Refill Requests:

Call our office at 916-999-1418 and select the medication refill option

Telephone Calls:

You can call our office with questions, to report side effects, or if your condition worsens. We will return your call as promptly as possible. Voicemails left after hours will be returned the next business day. You may also use http://www.eagleviewpsychiatry.com to communicate with staff during business hours. For true medical emergencies, call 911 or go to the nearest emergency room or urgent care.

Partial Invalidity:

If any provision of this agreement is found to be invalid or unenforceable by a court of competent authority, the remaining provisions will continue in full force and effect.

Termination Policy:

Eagle View Psychiatry maintains the right to end services at any time and for any reason. This could be due to missed appointments, insufficient communication or cooperation, or non-adherence to treatment guidelines. Similarly, you have the option to stop or refuse treatment, including medications, whenever you choose. It is important to communicate any concerns or issues regarding your care as soon as they arise, to ensure that we can provide you with the best possible service.

Authorization for Release of Information:

By signing this document, you grant permission for Eagle View Psychiatry to share and exchange your medical information with your primary care physician, referring physician, or any other relevant parties as needed. This exchange is intended to facilitate insurance payments and support the delivery of comprehensive and effective care.

Telehealth Consent

  1. I understand that my healthcare provider at Eagle View Psychiatry wishes me to participate in a telemedicine consultation.
  2. My healthcare provider has explained how the video conferencing technology will be used for this consultation, and that it differs from an in-person visit because I will not be physically present with my provider.
  3. I acknowledge that there are potential risks associated with this technology, including interruptions, unauthorized access, and technical issues. I understand that either my healthcare provider or I can terminate the telemedicine consultation if the videoconferencing connection is deemed inadequate for the situation.
  4. I understand that my healthcare information may be shared with others for scheduling and billing purposes. Additionally, individuals other than my healthcare provider may be present during the consultation to operate the video equipment. These individuals will maintain the confidentiality of my information. I will be informed of their presence and have the right to:
    • (1) Exclude specific details of my medical history or physical examination that are personally sensitive to me;
    • (2) Request that non-medical personnel leave the telemedicine consultation room; and/or
    • (3) Terminate the consultation at any time.
  5. I have been informed of the alternatives to a telemedicine consultation. I understand that some aspects of the examination, including physical tests, may be conducted by individuals at my location under the guidance of the consulting healthcare provider.
  6. In an emergency telemedicine consultation, I understand that the consulting specialist’s role is to provide advice to my local practitioner, and their responsibility ends when the video conference connection is terminated.
  7. I acknowledge that billing will be processed both by my healthcare provider and as a facility fee from the site where I am presenting.
  8. I have discussed this procedure directly with my doctor, had the opportunity to ask questions, and received answers. The risks, benefits, and any practical alternatives have been explained to me in a language I understand.
By signing this form, I certify that:
  • I have read or had this form read to me, or had it explained to me.
  • I fully understand its contents, including the risks and benefits of the procedure(s).
  • I have been given ample opportunity to ask questions, and all my questions have been answered to my satisfaction.

Therapy Consent

CONFIDENTIALITY

Information shared during therapy at Eagle View Psychiatry is protected by professional and ethical standards. All material is confidential and will not be released without your written consent, except in cases involving suspected child abuse, elder or dependent adult abuse, or situations where there is imminent harm to yourself or others.

INFORMED CONSENT

Engaging in therapy requires courage, commitment, and a willingness to take risks. It is possible that discussing certain topics in therapy may lead to distressing feelings or thoughts. At times, you might experience physical symptoms as a result of processing distressing information. Please share any discomfort with me so that we can work together to find ways to manage these feelings and thoughts. Each person's response to therapy is unique, and the duration and outcomes of the process cannot be precisely predicted. Each therapy session is 60 minutes long.

HIPAA

In accordance with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, I am required to provide a notice regarding my privacy practices related to your protected health information (PHI). This notice is posted on the wall of our office.

FEES AND PAYMENT

Your fee will be $175 the first session. Payment is due at the time of each session unless other arrangements have been made in advance. A $150 fee will be applied for returned checks.

CANCELLATIONS

Cancellations or changes to session dates or times must be made with at least 48 hours' notice. If an appointment is canceled or missed without 48-hour notice, you will be charged for the session. Please note that after your third missed or late-canceled session, I will no longer schedule appointments for you. Your signature indicates that you have read and agree to abide by the above policies.

Exchange Authorization

Authorization to Release or Exchange Confidential Information By Signing This Consent, You Are Agreeing to An Exchange of Information Between the Parties Below:

To whom should the information be released/exchanged?

428 J Street, Ste 400 Sacramento, 95814 California
Phone: 916-999-1418 Fax: 916-288-8886

Information type(s) to be released/exchanged:

Mental Health Information (Lantern-Petris-Short Act, WIC §5000 et seq.)
Medical (Including drug/alcohol and mental health information documented by a primary care practitioner)
Drug and Alcohol Abuse, Diagnosis or Treatment Information (42 C.F.R. § §2.3.4 and 2.3 5)
HIV/AIDS Test Results (Health and Safety Code §120980(g))
Generic/Genetic Testing Information (Health and Safety Code §120980(g))

PATIENT MEDICATION CONSENT FORM

  1. Medication Understanding: I have been informed about the nature and purpose of each medication prescribed for my psychiatric condition.

  2. Treatment Responsibilities: I understand my responsibilities in taking the medication as directed. I have reviewed the potential issues and benefits, and other relevant information has been explained to me.

  3. Side Effects: I have been made aware of the possible side effects of each medication, as outlined in the PDR (Physician's Desk Reference).

  4. Psychopharmacology Awareness: By signing this consent form, I acknowledge that I have been informed about the side effects, benefits of the medication(s), and the importance of maintaining a healthy lifestyle to prevent adverse reactions or interactions with other medications. I understand the consequences of overdose or noncompliance with the medication(s) and agree with the management plan.

  5. Controlled Substances: Medications that are classified as controlled substances require frequent monitoring, including monthly follow-up appointments to obtain refills. I have been informed that these medications can lead to dependence and addiction and should be stored securely, preferably in a locked container, away from children. Random urine drug screenings (UDS) will be required for ongoing medication management, and I will have 7 days to comply with such requests. Any discrepancies noted in UDS or on CURES drug monitoring reports may lead to termination from Eagle View Psychiatry. If receiving Schedule II medications from this office, I understand it is against this agreement to seek additional controlled substances from other providers during the prescription timeframe. Violations of the controlled substance policy may result in termination from Eagle View Psychiatry.I understand that my medication or drug therapy may be discontinued at the discretion of my physician if:

    • The physician determines that controlled substances are not effective for my pain or functional activity,
    • I misuse the medication,
    • I develop rapid tolerance or loss of effectiveness,
    • Significant and detrimental side effects occur,
    • I obtain controlled substances from other sources without informing my psychiatrist,
    • I am arrested or convicted for drug-related offenses, including DUI,
    • Any other violation of this agreement occurs.

  6. Alternative Medications: Possible alternative medications have been discussed with me. I agree with the current medication plan and the choice of medications.

  7. Medication Adjustments: Instructions for tapering down or increasing medications have been discussed, and I have been advised to follow these recommendations.I have received the above information. I understand that any changes in my medication will be discussed with me and that my medications will be periodically reviewed by my prescribing clinician. I am not obligated to take any medication I do not agree with, but if I choose to take it, I must follow the provider's instructions to avoid side effects or injury.

  8. Emergency Contact: In case of a serious emergency, I will call 911 or go to the nearest emergency room.