OUTPATIENT SERVICE CONTRACT
Welcome to Wildflower Holistic Psychiatry, LLC. This document contains important information about the professional services and business policies at WHP. Please read it carefully and jot down any questions that you might have so that we can discuss them at our next meeting. Once you sign the WHP Outpatient Service Contract/Consent to Treat/HIPAA signature page, it will constitute a binding agreement between us.
INTEGRATIVE PSYCHIATRY SERVICES
As part of your integrative psychiatry evaluation I will start with a full evaluation that will last at least one 90 to 120 minute session, but may require an additional session or two to complete if there is a lot of information to gather. At the following session we will discuss treatment plan options. Treatment plans may include discussion of medication and risks versus benefits (although you should know that I do not prescribe medications and you will be referred to an appropriate provider if necessary), psychotherapy, lifestyle and nutrition. It may also include, if you are interested, suggestions for complementary and integrative health modalities including the use of natural supplements, breathing exercises, mindfulness, meditation and energy techniques (such as Reiki). If complementary modalities are of interest to you as a path to wellness, we will discuss the potential benefits and risks of each, just as we would with medication choices. If you prefer not to incorporate these complementary modalities into your treatment plan, that is entirely your choice—and your responsibility to let me know. I practice based on a collaborative decision making model. While I am your resource in the field of child and adolescent mental health, you are the expert resource for your child or adolescent. This is a collaborative effort and journey that requires your participation. It is your responsibility to evaluate this information along with your own assessment about whether you feel comfortable working with me. lf you have questions about my procedures, we should discuss them whenever they arise. If your doubts persist, I will be happy to provide a referral to another mental health professional.
The fee for the initial evaluation is $375. My subsequent hourly fee is $150. If you have an appointment scheduled and choose to stay for only part of the scheduled time (including late arrival for appointments) this is your choice, but the hourly fee will still be charged as this time was set aside for you. How you choose to use it is up to you. In addition to appointments, it is my practice to charge this amount on a prorated basis for other professional services you may require such as report and letter writing, telephone conversations which last longer than 5 minutes, consultations with other professionals which you have authorized, preparation of records or treatment summaries or the time required to perform any other service which you may request of me. Printed copies of medical records will also incur a fee of $0.50 per page, plus the cost of mailing.
Initial Psychiatric Evaluation $375
60 Minute Follow Up $150
90 Minute Follow Up $225
My practice is fee-for-service. Payment is expected at the time of service. I accept check, cash and credit card. A fee of $30 will be charged for any returned checks or insufficient funds.
lf your account is more than 60 days in arrears and suitable arrangements for payment have not been agreed to, l have the option of using legal means to secure payment, including collection agencies or small claims court. (If such legal action is necessary, the costs of bringing that proceeding will be included in the claim.)
Working with your Insurance Company
I am out-of-network for all insurance plans and carriers. Health services may be covered in full or in part by your health insurance or employee benefit plan. Although I am considered out-of-network for all insurance carriers, many patients are able to obtain full or partial reimbursements from their insurance carriers. Out-of-network benefits vary among carriers. Clients may request a Super Bill with all the information needed to seek reimbursement from traditional insurers or from health care spending accounts. Any additional contact or communication with insurance companies is the responsibility of the insured. Super Bill statements are typically sufficient to obtain reimbursement.
You should also be aware that most insurance agreements require you to authorize me to provide a clinical diagnosis, and sometimes additional clinical information such as a treatment plan or summary, or, in some cases, a copy of the entire record. This information then becomes part of the insurance company files and I have no control over what they do with it.
Why I do not contract directly with insurance companies…
I have found that the current insurance payment system makes it impossible to devote the time necessary to fully meet my patients’ needs. Insurance companies limit treatment and care options and restrict the time a provider can spend with their patients. I choose not to work directly with insurance companies to ensure that I am able to spend the time needed with my patients to provide the highest quality of care possible. The mission of my practice is to help patients at a deeper level than the usual brief 15-20 minute psychiatric encounter allows It is the goal of Wildflower Holistic Psychiatry to use the body’s natural balance to heal and to maintain lifelong mental health.
In the event of an emergency please call 911 or go to your nearest emergency room for treatment.
Wildflower Holistic Psychiatry is unable to provide acute crisis assessment or response in the event of an emergency. Please consider it an emergency if you require care that could not wait 24 hours or more. At any time if you feel your life or the life of your child is in danger, please consider this an emergency.
Please DO NOT use text or e-mail to communicate with me about emergency concerns, please call 911 or go to your nearest emergency room for treatment. Once the immediate threat of harm or danger is resolved please contact me via phone with updates and we will schedule a time to meet for follow up.
Urgent and Non-Urgent Communication
I may not be immediately available by telephone as I will not answer the phone when I am with a client. When I am unavailable, please leave a message on my voice mail and I will get back to you as soon as possible. Please note that Wildflower Holistic Psychiatry uses Google Voice for phone calls, you will be asked to state your name and leave a message. There will be no WHP greeting. If you have a quick question regarding the time of your appointment feel free to text me and I may be able to respond more quickly.
For urgent messages please call 234.208.5772 and let me know that your concern is urgent, I will do my best to respond to your concern within 24 hours. Please note that if I am out of the office or out of the country I may have limited access to communication and you should use your best judgement in seeking treatment. I will make every effort to update the website at WildflowerHolistic.com if I expect to be unavailable.
For non-urgent messages please allow up to 48 hours for a response. You may call or text 234.208.5772 or e-mail WildflowerHolistic@gmail.com with no-urgent messages. I will make every effort to return your call, text or e-mail within 48 hours with the exception of weekends, holidays and vacations.
For concerns which require consultation above and beyond 10 minutes outside of the office I will request that you schedule an appointment. Please refer to the above mentioned fee schedule for charges associated with phone calls.
I understand that events arise and appointments cannot always be kept and must be rescheduled. I request, however, that you call 24 hours in advance to cancel or reschedule. This ensures that I have the opportunity to offer this time to another patient who may need it.
For cancellations made less than 24 hours in advance and missed appointments (no shows) your credit card will be charged in full for the scheduled visit. These charges must be paid at or before your next scheduled visit.
DISCHARGE POLICY :
If three or more appointments are missed without cancelling prior to the start time of the appointment (no shows), you will be dismissed from the practice. Please make every effort to either keep your appointment or call 24 hours in advance for cancellations to avoid discontinuation of services.
In general I do not prescribe medications although in some cases I will write prescriptions for labs, vitamins and supplements, please be sure to give 1 week notice for refill requests as it may be necessary to mail your prescription to your home if a suitable time for pick up at WHP cannot be arranged.
Federal law (HIPAA) protects the confidentiality of all communications between a client and practitioner. Please see the HIPAA Notice at www.WildflowerHolistic.com.
Should you have questions about these policies, please discuss them with me at your first session.
CONSENT TO TREAT
I voluntarily consent to outpatient care with Laura J. Abels, BA, MSN, RN, PHMCNS-BC, APHN-BC.
◦I understand Laura J. Abels, BA, MSN, RN, PHMCNS-BC, APHN-BC uses an integrative psychiatry and mental health approach, which may include but is not limited to evaluation of psychiatric issues, diagnostic testing, counseling labs and/or prescribe vitamins and supplements, I understand that Laura J. Abels, BA, MSN, RN, PHMCNS-BC, APHN-BC will not prescribe my medications.
◦I understand that the care I receive from Wildflower Holistic Psychiatry may be considered non-conventional. Such services are commonly referred to as integrative, complementary, alternative or holistic services. This can include nutritional and supplement recommendations, mindfulness and breathing practices, energy practices, guided imagery, hypnotherapy and other mind-body approaches to care. While many of these techniques have been long practiced, researched and found to be effective, many are still considered “investigative” or “experimental”. The treatment plan is a collaborative effort and I recognize it is my responsibility to let Laura J. Abels, BA, MSN, RN, PHMCNS-BC, APHN-BC know which approaches I would like to try and those with which I do not feel comfortable. I recognize it is entirely my choice. By accepting these treatments I agree to accept the risks explained to me about these treatments.
◦I understand that I am responsible for payment in full at the time of service as Laura J. Abels, BA, MSN, RN, PHMCNS-BC, APHN-BC will not bill my insurance and is not on any commercial or Medicaid insurance panels. I understand that I will be charged in full for visits if I do not give 24 hours’ notice of cancellation. Laura J. Abels, BA, MSN, RN, PHMCNS-BC, APHN-BC may furnish information on my behalf to my insurance company if requested.
◦I understand that e-mail and text message communication is not confidential. I acknowledge that e-mail or text messages may be coped and included in my medical record.
◦I have read and understand the Outpatient Service Contract and Consent for Treatment as it appears on www.WildflowerHolistic.com. I understand that I may request a copy of this document at any time. I understand that it is my responsibility to discuss any concerns I have about any and all parts of my treatment plan with my provider at Wildflower Holistic Psychiatry. I understand the nature of these health care methods and consent to counseling and treatment.
◦I have read and reviewed the HIPAA Privacy Statement available at www.WidflowerHolistic.com. I am aware of HIPAA privacy guidelines and have been offered a copy of this document. I understand my rights regarding the protection of my personal health information (PHI). I understand that I have a right to revoke the above authorization at any time.
My signature appears on the WHP Outpatient Services/Consent for Treatment/HIPAA Signature Form