PATIENT SERVICES AGREEMENT
Welcome to SAGE NEUROSCIENCE CENTER. Our dedicated psychiatric providers and staff are committed to providing the highest quality care for each and every patient. Set forth below is our Patient Agreement, which establishes guidelines for your participation in treatment with us. This document contains important information about our professional services, business policies, and our treatment expectations. If, after reading and considering the outlined terms, you agree to everything set forth below, please sign where indicated.
PSYCHOTHERAPY SERVICES
Psychotherapy has been shown to have multiple benefits, such as significant reduction of distress, improved daily functioning, improved relationships, resolution of significant problems, and a clearer understanding of yourself, your values, and your goals. However, there are no guarantees about what will happen in therapy. Psychotherapy requires your very active involvement, honesty, and openness to change your thoughts, feelings, and/or behaviors. For psychotherapy to be most successful, you will have put forth active effort inside and outside of sessions.
Psychotherapy can have risks as well as benefits, as it may require revealing unpleasant aspects of your history and current life. Therefore, in the initial stages of treatment, psychotherapy may include experiencing discomfort and unpleasant feelings like sadness, guilt, disappointment, frustration, anger, loneliness, and hopelessness and could impact your relationships with others. While unpleasant experiences are usually temporary, please let your provider know if they occur. It is important you consider carefully whether the risks are worth the benefits to you of changing. Most people who take these risks find therapy is helpful.
Your first few sessions will involve an evaluation of your needs. By the end of an evaluation period, your provider will be able to offer some initial impressions of what your work together will include, with a treatment plan to follow, if you decide to continue. If psychotherapy is initiated, your provider will usually schedule a 45-60 minute regular sessions. Therapy works best when there is a good fit between patient and provider. If questions about treatment, policies, and/or procedures ever arise, please discuss them with your provider. If doubts persist, our providers will be happy to help you secure an appropriate consultation with another mental health professional.
PSYCHIATRIC/MEDICATION MANAGEMENT SERVICES
Initial evaluations involve one, approximately 30-60 minute, session. Typically, your provider may need to obtain collateral information from your other providers before generating a more definitive diagnosis and/or recommendations.
Following the initial evaluation, your provider will discuss the assessment with you and make recommendations regarding medication and/or psychotherapy. Often, psychotherapy is a helpful adjunct to medication, or an effective stand-alone treatment for many emotional/ behavioral problems. If psychotherapy is recommended, we can refer you to in-house or local psychotherapists.
If your provider determines medication is needed, our staff will schedule follow-up sessions at medically appropriate intervals. During the initial phase of treatment, your provider will need to carefully monitor your response to medications and their potential side effects. These follow up sessions typically last 20-30 minutes, although they may take somewhat longer in the early stages of treatment.
Discussions between you and your provider and your provider’s clinical observations serve as the foundation for choosing medications. For certain situations and particular medications, your provider may request various laboratory tests, including urine, saliva, and/or blood screens, prior to starting and/or continuing medication.
The initial stages of treatment may require several trials of different medications to choose those which are most effective and cause the least side effects. As with most medications, psychiatric medications may result in adverse side effects (e.g. dry mouth, constipation, stomach upset, diarrhea, or mild headache) which often subside after several weeks (your provider will discuss specific potential side effects with you prior to starting you on a medication). For this reason, you will likely meet more frequently with your provider at beginning of treatment.
MEDICATION TREATMENT AGREEMENT
If you and your provider decide to start medication, you agree to take the medication only as prescribed and to contact your provider before any changes are made.
You agree to submit to urine, saliva, and/or blood screens at any time as determined by your provider to detect the use of both prescribed and non-prescribed medication.
You understand that if you miss your appointment or are more than 10 minutes late to your appointment, you will be rescheduled and you will not receive medication.
You are responsible for keeping track of the amount of medication you have remaining. If your medication is stolen, you will report this to your local police department and obtain a stolen item report. Lost, misplaced, or stolen medication/prescriptions will likely not be replaced.
All requests for prescription refills should be submitted through your chosen pharmacy during business hours. The pharmacy will send the information needed for our providers to review the request and respond accordingly.
Refill requests require a minimum of 72 business hours notice. This will allow time for the pharmacy to contact Sage Neuroscience Center, for your provider to review requests, and for the response to be sent back to the pharmacy. If a prescription is in written format, it will be ready for you to pick up. Sage does not fax or mail prescriptions to patients.
Refill requests are not reviewed after 4:30p.m. on Fridays, over the weekends, or when Sage is closed for legal holidays.
MISSED APPOINTMENTS/CANCELLATION POLICY
We reserve your appointment time specifically for you and you alone. For this reason, we charge for cancellations without at least 24-hours notice or one business day prior. While we understand that occasional emergencies will prevent timely cancellations, we respectfully ask that you give your appointments special priority. Missed or cancelled visits not only jeopardize the quality of your care but create a financial burden for your provider. If you arrive late for your appointment, we cannot guarantee you will be seen by your provider. If your provider agrees, you may only be seen for the allotted time left of your scheduled appointment. At such times, it may be necessary to schedule an additional appointment to address treatment concerns sufficiently.
Please note:
If you need to reschedule/cancel your appointment, we require you notify us at least 24 hours or one business day prior to your scheduled appointment. There is a significant need in the community to see providers at Sage and whenever possible, we like to fill cancelled spaces to shorten the waiting period for our patients.
If less than a 24-hour cancellation is given, this will be documented as a “No-Show/Missed” appointment.
If you do not present to the office for your appointment, this will be documented as a “No-Show/Missed” appointment.
If you have 2 “No-Show/Missed” appointments within a one-year time period, you will receive a warning letter from our office.
If you have 3 “No-Show/Missed” appointments within a one-year time period, dismissal from the practice will be suggested. In this instance, you will be notified by letter, which will include referral sources that you may utilize for your continued care. In the instance of a dismissal, you will receive an adequate supply of medically necessary medications only.
Insurance companies do not reimburse for “No-Show/Missed” appointments. Each
“No-Show/Missed” appointment will incur a $50 administrative fee, for non-Medicaid patients.
We also understand that your time and money is valuable. For this reason, our office staff typically extends a courtesy reminder call for each appointment. Again, this is a courtesy and not a guarantee. You are responsible for attending scheduled appointments. Please notify our staff if you do not wish to be contacted at either your home or your office.
PROFESSIONAL FEES
Payment/Co-payment in full is expected at the time of each session. For patients not contracted with insurance carriers, sliding-scale fees are available on a case-by-case basis.
Standard rates are as follows:
Medical Evaluations and Medication Assessment/Management
- Initial Assessment: Up to $325, including specialty services
- Subsequent/Follow-Up Visit: Up to $325, depending on complexity and type of service Some services may be additional.
Psychotherapy Services
- Initial Assessment: Up to $210 hourly
- Subsequent Sessions: Up to $180 hourly
- Some services may be additional.
Additional Services
Services typically not covered by insurance include (but are not limited to) telephone conversations, letters, disability forms and the like, site visits, consultations, and legal requests. These services will be provided at the discretion of the provider and charged various hourly rates, based on service provided.
INSURANCE REIMBURSEMENT
You are responsible for your incurred health expenses. If we are contracted with your insurance, you will still be responsible for co-payments, co-insurance, and any non-covered services. It is important to evaluate what resources you have available to pay for your treatment to set realistic treatment goals and priorities. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. By signing this form, you are authorizing Sage Neuroscience Center to bill your insurance company on their required forms and to give them any required information they may require for authorization and/or billing purposes. You are agreeing to provide documentation (i.e. insurance cards) related to your insurance coverage when requested. You are also agreeing to pay Sage Neuroscience Center the full fee for services rendered if your insurance company fails to cover those services. You are also agreeing to pay for services yourself after your insurance authorized sessions reach policy limits. Ultimately, you (not your insurance company) are responsible for full payment of professional fees. It is critical that you find out exactly what mental health services your health insurance policy covers.
CONFIDENTIALITY AND EXCEPTIONS
Information pertaining to your treatment (including the fact that you receive services at Sage Neuroscience Center) is strictly confidential. However, there are some exceptions to confidentiality. There are certain situations in which your provider is legally required to take action that requires revealing information about your treatment.
Exceptions to Confidentiality
In most situations, providers can only release information about your treatment to others if you sign a written authorization form that meets certain legal requirements imposed by HIPAA. Other situations require only that you provide written, advance consent. Your signature on this document provides consent for those activities, as follows:
Consultation: Providers commonly consult with other professionals regarding patient cases. Patient identity remains completely anonymous.
Health Insurance Carriers (Third Party Payors) and Confidentiality of Records: Your contract with your health insurance company requires that disclosure of confidential information to process payment claims. Providers are required to provide a clinical diagnosis. Additional clinical information such as treatment plans, summaries, and sometimes entire clinical records may be required. In such situations, providers will make every effort to release only the necessary information needed per the requested purpose. Sage Neuroscience Center has no control over what insurance companies do with submitted information or no knowledge of who has access to submitted information. Submitting a mental health invoice for reimbursement can carry a certain amount of risk to confidentiality, privacy, the future capacity to obtain health/life insurance, or obtain gainful employment.
There are situations in which providers are permitted and/or required to disclose information without your consent or authorization.
Legal Proceedings: Disclosure may be required pursuant to a legal proceeding by or against you. If you place your mental status at issue in litigation initiated by you, the defendant may have the right to obtain psychotherapy records and/or testimony by providers at Sage Neuroscience Center.
If a government agency is requesting information for health oversight activities, providers may be required to break confidentiality.
If a patient files a complaint or lawsuit against a provider, relevant information about the patient may be disclosed in order to defend the provider.
If a patient files a worker’s compensation claim, providers must – upon appropriate request – disclose appropriate information, including a copy of the patient’s record, to the the patient’s employer, the insurer, or the Department of Worker’s Compensation.
Couples/Family/Group Therapy: In couples, family, or group therapy, confidentiality and privilege do not apply between the couple or among family and group members, unless otherwise agreed upon. Providers will use clinical judgment when revealing such information. Sage Neuroscience Center will not release records to any outside party unless authorized to do so by all adult family members who were part of the treatment.
There are situations in which providers are legally obligated to take action.
Child Abuse/Neglect: If a provider believes a child under the age of 18 is suffering physical or emotional injury resulting from abuse inflicted upon him or her which causes harm or substantial risk of harm to the child’s health or welfare (including sexual abuse), or from neglect (including malnutrition), the law requires a provider file a report with the appropriate Department of Child Protective Services. Once such a report is filed, a provider may be required to provide additional information.
Elderly Abuse: If a provider believes an elderly or handicapped individual is suffering from abuse, the law requires a provider files a report to the appropriate Department of Adult Protective Services. Once such a report is filed, a provider may be required to provide additional information.
Harm to Others: If a patient communicates an immediate threat of serious physical harm to an identifiable victim or if a patient has a history of violence and the apparent intent and ability to carry out the threat, a provider may be required by law to take protective actions. These actions may include notifying the potential victim, contacting the police, and/or seeking hospitalization for the patient.
Harm to Self: If a patient threatens to harm himself/herself, a provider may be required by law to seek hospitalization for the patient or to contact family members or others who can help provide protection.
If such a situation arises, providers will make the effort to fully discuss plans with you prior to taking any action and will limit disclosure to what is necessary.
Litigation Limitation: Due to the nature of the mental health process and that it often involves making a full disclosure with regard to many confidential matters, it is agreed that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries, lawsuits, etc.), neither you (patient), your attorney, nor your anyone else acting on your behalf will call on your provider at Sage Neuroscience Center to testify in court or at any other proceeding. Disclosure of psychotherapy records will not be requested unless otherwise agreed upon.
While this summary of exceptions to confidentiality should help inform you about any potential problems, it is important that you discuss any questions or concerns you may have now or in the future with your provider. The laws governing confidentiality can be complicated, and our providers are not attorneys. Formal legal consultation is recommended for situations in which specific advice is needed.
CLINICAL RECORDS AND PATIENT RIGHTS
The laws and standards of the medical profession require that providers at Sage Neuroscience Center keep Protected Health Information (PHI) in your clinical record. As a patient, you have the right to examine and/or receive a copy of your records if you submit a request in writing. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. In certain situations, you (or a representative on your behalf) will be provided with a treatment summary if your provider believes full access to your record would be harmful to you. Sage Neuroscience Center recommends that you initially review your record in the presence of your provider. Considering all the above exclusions, if it is still appropriate, upon your request, Sage Neuroscience Center will release information to any agency/person you specify unless releasing such information might be harmful in any way.
Our record requests are managed through an outside company which adheres to all HIPAA rules and regulations. Please allow up to 30-45 days for record requests to be fully processed. For any questions regarding your clinical record and/or a record request, please contact our office.
HIPAA provides you with several new or expanded rights with regard to your Clinical Record and disclosures of PHI. These rights include requesting amendments to your record, requesting restrictions on what information from your Clinical Record is disclosed to others, requesting an accounting of most disclosures of PHI that you have neither consented to nor authorized, determining the location to which protected information disclosures are sent; having any complaints you make about Sage Neuroscience Center’s policies and procedures reported in your records, and the right to paper copies of Sage Neuroscience Center’s privacy policies and procedures.
EMERGENCY CONTACT PROCEDURES
If you need to contact your provider between sessions, please call our office at (505) 884-1114 and speak to one of our staff or leave a message. Providers are often not immediately available by phone. Your call will be returned as soon as possible. If you are difficult to reach, please inform your provider of the best times you are available. For emergencies, please do not call our office. Please call 911 or go directly to the emergency room at your nearest hospital.
DUAL RELATIONSHIPS
Not all dual relationships are unethical or avoidable. Psychiatric/Psychotherapeutic services never involve sexual or any other dual relationship that impairs your provider’s objectivity, clinical judgment, therapeutic effectiveness, or that can be exploitative in nature. Providers at Sage Neuroscience Center will carefully assess before entering into non-sexual and non-exploitative dual relationships with patients. There are chances you may know other patients, staff, or providers at Sage from the community. Providers at Sage Neuroscience Center will not readily acknowledge working with you without your express permission if you meet them in the community. Providers will discuss with you the often-existing complexities, potential benefits, and difficulties that may be involved in such relationships. Dual or multiple relationships can enhance therapeutic effectiveness but can also detract from it, and often it is impossible to know that ahead of time. It is your responsibility to inform us if the dual relationship becomes uncomfortable for you in any way.
FREEDOM TO WITHDRAW/TERMINATION
You have the right to choose not to receive psychiatric services from any provider employed at Sage Neuroscience Center. If you choose this, we will make every effort to provide you with names of other qualified professionals whose services you might prefer. You have the right to terminate your services at any time without any financial or legal obligations other than those you have already incurred.
If you choose to leave your appointment before a provider has completed the entire visit, this may be considered an automatic self-discharge.
A provider has the right to terminate services with you if it is believed that services are no longer beneficial to you, if a provider believes you will be better served by another professional or a higher level of care, when you have not met financial obligations unless special arrangements have been made, or when you have failed to attend three scheduled appointments without 24 business hours notice in a twelve-month period. If any of these decisions have been made, a letter to inform you will be sent to your address on record.
CODE OF CONDUCT FOR PATIENTS
In an effort to provide a safe and healthy environment for staff, visitors, patients, and their families, Sage Neuroscience Center expects visitors, patients, and accompanying
friends/family members to refrain from unacceptable behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff.
The following behaviors are prohibited:
- Possession of firearms or any weapons.
- Physical assault, inflicting bodily harm, or arson
- Throwing objects
- Climbing on furniture or toys (Adults are expected to supervise children in their care)
- Making verbal threats to harm another individual or destroy property
- Intentionally damaging equipment or property
- Making menacing gestures
- Attempting to intimidate or harass other individuals
- Making harassing, offensive or intimidating statements, badgering of staff (including multiple phone calls, i.e. more than three (3) on the same business day regarding the same question or request), or threats of violence through phone calls, letters, voicemail, email, or other forms of written, verbal, or electronic communication
- Racial or cultural slurs or other derogatory remarks associated with, but not limited to, race, language, or sexuality
If you are subject to any of these behaviors or witness inappropriate behavior, please report to any staff member. Violators are subject to removal from the property and/or discharge from Sage Neuroscience Center.
COMPLAINTS AND GRIEVANCES
Complaints and grievances regarding any services received at Sage Neuroscience Center should be addressed to Management in writing to 7850 Jefferson St. NE Suite 300, Albuquerque, NM 87109. Where needed, these grievances will be brought up with the management team and/or clinical and medical directors. Please include your name and contact number when writing.
