PATIENT INFORMATION

We would like your experience at StressCare Behavioral Health, Inc. (SCBH) to be a positive one. The following information will help you to understand our treatment practices, fees, and policies. Hopefully this information is clear, but feel free to ask questions at any time.

INFORMATION SHEET – It is very important that you complete the Information Sheet as completely and accurately as possible, including any medications you may be taking. We use this information in order to contact you, make treatment decisions, and to bill your insurance company. Please inform us promptly if any of your information changes. Signing the bottom of this sheet provides us with consent to treat you and to bill your insurance company. We cannot see you without this information and your signature.

TELEPHONE COMMUNICATION - You may leave a message for your clinician at any time. The answering service is available to take messages any time the office is closed. Clinicians will accept brief telephone calls, when they are available, at no charge. Calls longer than five minutes will be billed at the usual rate.

As a result of confidentiality rules, we will not share any information about you with family or friends and will not accept telephone calls from them unless you are incapacitated or the patient is a minor. If you need to communicate with us about appointments, billing issues, forms, or other matters, please call us yourself. We will not speak with family members (including spouses) if they telephone.

THERAPY SESSIONS -Typical therapy sessions last 45-50 minutes and are not interrupted by telephone calls. Usually you will be seen alone, unless you are being seen for marital, couples, or family treatment. Sometimes you may be asked to invite a family member or friend to join you in the treatment session, if that is relevant to your care.

CONFIDENTIALITY-It is important to us that this can be a safe place for you to talk about your problems. We treat what you say with respect and care. The things we discuss in our treatment sessions are confidential, meaning we do not share information with anyone else without your written permission. There are some exceptions to confidentiality, though, which are dictated by law. We are required to report to the appropriate authority if we suspect abuse or neglect of a child, mentally or physically handicapped individual under the age of 21, a vulnerable adult, or a mentally retarded or developmentally disabled adult. If we suspect that you are a victim of domestic violence we are required to make note of that in your record. If we have reason to believe that you or someone else is in danger, we are required to take some kind of protective action, which could include telling someone, even without your permission to share this information. Sometimes insurance companies require information about what is being discussed in treatment in order to authorize care. In this case, we only share relevant information and the insurance company is required to keep this information confidential. When a particular clinician is out of town or unavailable, they may share some of your information with another clinician so they can be available to help you. Of course, that clinician will also keep your information confidential. If you have any questions about whether we can keep information you share confidential, please talk with us about it before you share the information.

ATTENDING APPOINTMENTS -We believe that the doctor patient relationship starts with mutual respect and courtesy. With this in mind, we make every effort to be on time for appointments and not to change appointments once they have been scheduled. In return, we ask that you take your appointment times seriously, attend appointments regularly, and not cancel or miss appointments. When you do not keep appointments regularly, it is difficult for us to help you. As a result, if you miss or cancel two or more appointments with less than 24 hours notice, your treatment may be stopped. Sometimes when people begin to feel better, they feel they do not need to come to appointments anymore. If you start to feel this way, please discuss this with us. That way we can plan with you to terminate your treatment or help you to recognize that you are not yet ready to be done with treatment.

MISSED APPOINTMENTS AND CANCELLATIONS -It is our policy to bill patients for appointments that are missed or canceled with less than 24 hours notice. This fee is assessed regardless of the reason for missing or canceling the appointment. If we are able to fill the appointment time, even though less than 24 hours notice if given, we will not charge you for that appointment. It is important to understand that we do this as a courtesy and cannot guarantee that we will be able to fill the appointment. In that case, you would be billed for the missed appointment. The charge for appointments missed or canceled with less than 24-hour's notice is $25.00. This fees cannot be billed to your insurance company and is your responsibility.

REFERRALS AND INSURANCE CLAIMS -It is your responsibility to obtain required referrals or authorizations prior to your visit. We will file primary and secondary insurance claims for your visits, so it is important for you to inform us immediately of any changes in your insurance coverage. We cannot guarantee payment from your insurance company, since your insurance policy is a legal contract between you and your insurer. If your insurance carrier denies your claim or pays you directly, you are responsible for any outstanding balance owed to us. We will do everything we can to help you receive these benefits, but you are ultimately responsible for payment for services.

FEES-Fees are $225.00 for the initial evaluation session and $190.00 per session thereafter. Payment of fees, co-pays, or co:- insurances are due at the time of your visit and can be paid by cash, check, credit card, or debit card. There is a $5.00 fee for any co-pay that is not paid at the time of the visit. We do not send bills for co-payments. We will inform you at each visit what your financial responsibility is, based on the information your insurance company has given us. We cannot guarantee they have given us accurate information. There is a fee of $20.00 for returned checks.

PSYCHOLOGICAL TESTING -Sometimes psychological testing is necessary and is not covered by the insurance carrier. In these cases, testing charges are billed at the same hourly rate and include both the time to administer and interpret the test. The Minnesota Multiphasic Personality Inventory-2nd Edition (MMPI-) is billed at a flat rate of $100.00.

EMERGENCIES The answering service is available to take emergency calls anytime the office is not open. A clinician is always on call to take emergency calls. Please understand that your clinician will not be available to take these calls unless they happen to be the clinician on call at the time you call. If you are in danger of hurting yourself, please go immediately to the emergency department of your nearest hospital.

All of this information can be complicated and hard to remember. We encourage you to print and keep this paper handy while you are in treatment with us and refer to it whenever you have questions.

Please feel free to discuss with us any questions or concerns you may have about this information, as well.

I have read the above policies of StressCare Behavioral Health and agree to abide by them.