New Patient Form

I acknowledge receipt of the Notice of Telehealth Services. I am the patient or the legal representative of the patient and am authorized to act on the patient's behalf to sign this agreement. This includes my email and phone communication preferences.

This notice describes how medical information about you may be used and disclosed, as well as how you can get access to this information, Please review carefully. Effective date September 25, 2017

Introduction

Your health record contains personal information about you and your health. This information about you that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services is referred to as Protected Health Information ("PHI"). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law, including the Health Insurance Portability and Accountability Act ("HIPAA"), regulations promulgated under HIPAA including the HIPAA Privacy and Security Rules. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of this Notice of Privacy Practices.

How will we use and disclose information about you?

Treatment: Your PHI may be used and disclosed by those who are involved in your care for the purpose of providing, coordinating or managing your health care treatment and related services. This Includes consultation with clinical supervisors or other treatment team members. We may disclose PHI to any other consultant with authorization.

Payment: We may use and disclose PHI so that we can receive payment for the treatment services provided to you such as: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to determine medical necessity, or undertaking utilization review activities. If it becomes necessary to use collection processes due to lack of payment for services, we will only disclose the minimum amount of PHI necessary for purposes of collection.

Health Care Operations: We may use or disclose your PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing and conducting or arranging for other business activities. For example, we may share your PHI with third parties that perform various business activities (eg, billing or typing services) provided we have a written contract with the business that requires it to safeguard the privacy of your PHL For training or teaching purposes PHI will be disclosed only with your authorization.

Required by Law: Under the law: we must disclose your PHI to you upon your request, make disclosures to the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule, and disclose your PHI to a state or local agency authorized to receive reports of abuse or neglect of a child or vulnerable adult. Federal, state, or local laws do not require patient consent to disclose Information which is required to be reported.

Judicial Proceedings: We may disclose your PHI pursuant to a subpoena (with your written consent), court order, administrative order or similar process.

Deceased Patients: We may disclose PHI regarding deceased patients as mandated by state and federal laws, or to a family member or friend that was involved in your care or payment for care prior to death, based on prior consent. A release of information regarding deceased patients may be limited to an executor or administrator of a deceased person's estate or the person identified as next-of-kin. PHI of persons that have been deceased for more than fifty (50) years is not protected under HIPAA.

Medical Emergencies: We may use or disclose your PHI in a medical emergency situation to medical personnel only in order to prevent serious harm. Our staff will try to provide you a copy of this notice as soon as possible after the resolution of the emergency.

Family Involvement in Care: We may disclose information to close family members or friends directly involved in your treatment based on your written consent, verbal consent, or as necessary to prevent serious harm.

Health Oversight: If required, we may disclose PHI to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies and organizations that provide financial assistance to the program (such as third-party payers based on your prior consent) and peer review organizations performing utilization and quality control.

Coroners, Medical Examiners: Brain Solutions may disclose medical information concerning deceased patients to coroners or medical examiners to assist them in carrying out their duties

Law Enforcement: We may disclose PHI to a law enforcement official as required by law, in compliance with a subpoena (with your written consent), court order, administrative order or similar document, for the purpose of identifying a suspect, material witness or missing person, in connection with the victim of a crime, in connection with a deceased person, in connection with the reporting of a crime in an emergency, or in connection with a crime on the premises.

Specialized Government Functions: We may review requests from U.S. military command authorities and disclose your PHI based on your written consent if you have served as a member of the armed forces. Authorities include the department of Veterans Affairs, authorized officials for national security and intelligence reasons, the Department of State for medical suitability determinations, mandatory disclosure laws, and the need to prevent serious harm.

Information with Additional Protection: Certain types of medical Information may have additional protection under state or federal law. For instance, medical information about alcohol abuse treatment, psychotherapy notes, genetic testing, or court ordered mental health evaluations.

Health Information Exchange (HIE): We are a participating provider in a non-profit, non-governmental health information exchange (HIE) called Health Current Healthcare providers, and health plans better coordinate your care by securely sharing your health information. You have certain rights regarding HIE under state and federal law. Information is shared for treatment, care coordination, care or case management, and transition of care planning and population health services. Federal and state laws, such as HIPAA, protect the confidentiality of your health information. You have the right under article 27, section 2 of the Arizona Constitution and Arizona Revised Statutes title 36, Section 3802 to keep your health information from being shared electronically through Health Current: 1. You may "opt out of having your information available for sharing through Health Current.

Other Uses and Disclosures: Other uses and disclosures not described in this Notice will be made only with your written authorization such as sale of medical information. You may revoke such an authorization by sending us a written request.

What are your rights?

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer, Jonathan C. Mackey at Brain Solutions PLLC, 1835 W Chandler Blvd, Suite 100, Chandler, AZ 85224.

Right of Access to inspect and Copy: You have the right, which may be restricted only in exceptional circumstances, to inspect and copy PHI that is maintained in a designated record set". A designated record set contains mental health/medical and billing records and any other records that are used to make decisions about your care. Your right to inspect and copy PHI will be restricted only in those situations where there is compelling evidence that access would cause serious harm to you or if the information is contained in separately maintained psychotherapy notes. We may charge a reasonable fee for copies. If your records are maintained electronically, you may also request an electronic copy of your PHI. You may also request that a copy of your PHI be provided to another person.

Right to Amend: If you feel that the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy. Please contact the Privacy Officer if you have any questions.

Right to Request Restrictions: You have the right to request restriction or limitation on the use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request unless the request is to restrict disclosure of PHI to a health plan for purposes of carrying out payment or health care operations, and the PHI pertains to a healthcare item or service that you paid for out of pocket. In that case, we are required to honor your request for a restriction.

Right to Request Confidential Communication: You have the right to request that we communicate with you about health matters in a way you feel is more confidential. We will accommodate reasonable requests. We may require information regarding how payment will be handled or specification of an alternative address or other method of contact as a condition for accommodating your request.

Breach Notification: If there is a breach of unsecured PHI concerning you, we may be required to notify you of this breach, including what happened and what you can do to protect yourself.
Right to a copy of this Notice: You have the right to a copy of this notice. You may obtain a copy of the notice from our web site at www.brainsolutionscenter.com or obtain a paper copy at the office.

Changes to this notice

We reserve the right to change the terms of our Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will provide you with a copy of the revised Notice of Privacy Practices by posting a copy on our website, or providing a copy upon request.

Do you have any concerns, complaints, or questions?

If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer, Jonathan C. Mackey at Brain Solutions PLLC, 1835 W Chandler Blvd, Suite 100, Chandler, AZ 85224 by calling (480) 779-9050 or with the Secretary of Health and Human Services at 200 Independence Avenue, S.W. Washington, D.C. 20201 or by calling (202) 619-0257. We will not retaliate against you for filing a complaint.

Welcome to Brain Solutions. This document contains important information about our professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law providing privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations.


Patient/Provider Relationship


Behavioral health treatment involves a relationship between people that works due to clearly defined rights and responsibilities held by each person. There are legal limitations to those rights that you should be aware of. You and your provider with Brain Solutions will establish a professional relationship existing exclusively to provide therapeutic treatment.

Prescription Refills

All providers are required to evaluate a patient before prescribing any new medications or refilling existing prescriptions; taking into account patient medical history, other medications, and allergies. The office will refill prescriptions during your scheduled appointments. You may contact your pharmacy regarding prescription refills. No prescriptions will be authorized after hours or on weekends. All providers reserve the right to decline a prescription refill request when an appointment is necessary for medication evaluation and management. Plan ahead at least 10 business days for your refill request. If the medication is a controlled substance, the law requires a written prescription. You will need to set up a follow-up medication refill appointment.

Appointments

Appointments will ordinarily be 50 minutes in duration for psychotherapy and 15 minutes for psychiatric evaluation and management, although some sessions may be more or less time as needed. The time scheduled for your appointment is assigned to you and you alone. You are responsible for arriving 15 minutes prior to your appointment time. If you are less than 15 minutes late, it is up to the discretion of the provider if you are to be seen.

Cancellation/No Show Appointment Policy

If you need to cancel or reschedule an appointment, please provide us with at least a 24-hour notice. If you miss a scheduled appointment without contacting us for cancellation, or cancel with less than a 24-hour notice, our policy is to assess a $100.00 fee payable to Brain Solutions (unless you and your provider both agree that you were unable to attend due to beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the full fee amount as described above. Brain Solutions reserves the right to suspend services until the fee is paid. Excessive appointment no shows and frequent late arrivals is grounds for discharge from our services. This includes cancellations without the required 24-hour notice. This cancellation policy is standard in most medical and behavioral health practices and will be strictly enforced.

*Patients covered under TXIX/TXXI healthcare benefits are exempt from paying a fee.

Professional Records

The laws and standards of our profession require that we keep treatment records. Your records are maintained in a secure online system that meets or exceeds the HIPAA Security Rule. Although psychotherapy often includes discussion of private information, normally records are kept very brief and note the time and location of the visit, what was done in session, goal progress, and diagnoses.

Except in unusual circumstances, you have the right to request a copy of your records. In certain situations where there is compelling evidence that access may cause harm to you, Brain Solutions recommends that you review your records with a provider. We recommend that your review them in the presence of your provider. You have the right to request that a copy of your file be made available to any other health care provider through your written request for Release of information. Patients will be charged a $25.00 fee for records.

In the event of Brain Solutions terminating the practice, active patients will be notified and may locate their provider by calling a number provided to them via letter, email phone call, or direct verbal communication. For reasons of personal privacy Brain Solutions will only provide direct access to current or recent patients providing them with available contact numbers. Brain Solutions will maintain a contact number for a period of three to six months, depending on circumstances at the time of closing of the practice. Brain Solutions will dispose of unclaimed records after the current legal and/or legally specified time requirements. In the event that circumstances require, Brain Solutions will forward record access and responsibility to another professional who will respond to record requests in accordance with legal and professional guidelines.

Confidentiality

You have the right to the confidentiality of your treatment, with a few specific exceptions described here. Brain Solutions will not disclose any information you have shared with Brain Solutions without your prior written permission outlined in the Consent for Evaluation and Treatment Form. You will be notified if treatment is being provided by an unlicensed provider who is directly supervised by a licensed provider. You may request anyone of your choosing to attend a therapy session with you.

You are protected under the provision of HIPAA, insuring the confidentiality of all electronic transmission of information about you. It will be done with special safeguards to insure confidentiality and security.

If you elect to communicate with your provider by email during your work together, please be aware that email is not completely confidential and there are inherent risks to the security of this information. Any email Brain Solutions receives from you, and any responses that we send to you, may be copied and kept in your treatment record.

There are a limited number of situations in which Brain Solutions is required by law and ethical standard to disclose information about you without your authorization. Please read the Brain Solutions Notice of Privacy Practices for more information.

Providers will occasionally consult with other professionals about a case, taking every effort to maintain patient confidentiality. The consultant is legally bound to keep any information confidential. Providers will inform patients of consultations if it pertains to the treatment process.

Contact Information

Brain Solutions PLLC
1835 W. Chandler Blvd, Suite 100
Chandler, AZ 85224
Phone: (480) 779-9050
Fax: (480) 717-4025
Website: www.brainsolutionsAZ.com

If, for any reason, you are not able to reach your provider and you feel that you cannot wait for a return call and/or feel unable to keep yourself safe, CALL 9-1-1 or go to the nearest emergency room and ask for the social worker/psychologist/psychiatric provider on call. Brain Solutions does not provide crisis services. If you are experiencing a crisis and need to get assistance with behavioral health services, in addition to the options above, you may contact the National Suicide Prevention Lifeline at 1-800-273-8255, Maricopa County Crisis line 1-800-631-1314 or 602-222-9444, or 1-866-495-6735 if outside of Maricopa County.

I agree that in return for the services provided to me or the patient (if a different person - hereafter the word 'patient' applies to both) by Brain Solutions PLLC or other affiliates, I will pay the account of the patient and/or make financial arrangements satisfactory to Brain Solutions PLLC. Payment for services is due in full at the time services are rendered. If the service is not paid in full at the time of the appointment, the session is subject to cancellation per the discretion of Brain Solutions PLLC. Payment amounts vary and are dependent on the type of services provided. Brain Solution's staff will provide you with an estimate at the time of service. If an account is sent to an attorney for collection, I agree to pay reasonable attorney's fees and collection expenses in addition to the amount due and owing on the bill for medical and behavioral health services rendered to the patient if I am ultimately found to be liable for the bill. I understand and agree that a delinquent account will be subject to interest at the legal rate.

I understand and agree that my insurance and/or the patient's' insurance, if any, will NOT be billed for services rendered to the patient. I further understand and agree that as part of the normal business communication with Brain Solutions PLLC, with regard to this matter, Brain Solutions PLLC staff or representatives may contact me through any of the following methods: letter, email, telephone, text/voice message, or any other available technologies used by businesses for such communications. It is understood and agreed, however, that the patient and I may be contacted using an auto-dialer during collection proceedings.

If you need to cancel or reschedule an appointment, please provide us with at least a 24-hour notice. If you miss a scheduled appointment without contacting us for cancellation, or cancel with less than a 24-hour notice, our policy is to assess a $100.00 fee payable to Brain Solutions (unless you and your provider both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the full fee amount as described above. Brain Solutions reserves the right to suspend services until the fee is paid. Excessive appointment no shows and frequent late arrivals is grounds for discharge from our services. This includes cancellations without the required 24-hour notice. This cancellation policy is standard in most medical and behavioral health practices and will be strictly enforced.

In the event that the patient has a payment on an active account, whether through cash, check, credit card or other means, and there remain additional funds available after that account is satisfied (e.g. an overpayment), Brain Solutions PLLC is authorized to apply the overpayment to any other account owed by the patient that remains unpaid. Brain Solutions reserves the right to charge a nominal processing fee for all credit card transactions.

I have read, understand, and agree to adhere to Brain Solutions PLLC's Private Pay Agreement as stated above.

I agree that in return for the services provided to me or the patient (if a different person - hereafter the word 'patient applies to both) by Brain Solutions PLLC or other affiliates, I will pay the account of the patient and/or make financial arrangements satisfactory to Brain Solutions PLLC. Unless the patient's bill is paid by applicable insurance, government programs or other sources, I agree to pay Brain Solutions PLLC's usual and customary charges. If an account is sent to an attorney for collection, I agree to pay reasonable attorney's fees and collection expenses in addition to the amount due and owing on the bill for medical and behavioral health services rendered to the patient if I am ultimately found to be liable for the bill. I understand and agree that a delinquent account will be subject to interest at the legal rate.

I understand and agree that my insurance and/or the patient's' insurance, if any, will be billed for services rendered to the patient. Payment from the insurer will be sought by Brain Solutions PLLC before I am required to make payment (with the exception of some percentage of co-insurance or co-payment, which I must pay) I understand and agree that I am responsible for knowing my coverage and being transparent with any coverage changes. I further understand and agree that as part of the normal business communication with Brain Solutions PLLC, with regard to this matter, Brain Solutions PLLC staff or representatives may contact me through any of the following methods: letter, email, telephone, text/voice message, or any other available technologies used by businesses for such communications.

If the patient is entitled to any benefits whatsoever, under any policy of health, liability insurance, or from any other party liable to the patient, these benefits are hereby assigned to Brain Solutions PLLC and/or to the providers rendering services for application toward the patient's bill. I authorize the release of any medical and/or account information necessary to process claims/direct payment of benefits from my insurance company and collect payment for services rendered, including any applicable service charges and applicable costs of collections. It is understood and agreed, however, that the patient and I may be contacted using an autodialer during collection proceedings.

If you need to cancel or reschedule an appointment, please provide us with at least a 24-hour notice. If you miss a scheduled appointment without contacting us for cancellation, or cancel with less than a 24-hour notice, our policy is to assess a $100.00 fee payable to Brain Solutions (unless you and your provider both agree that you were unable to attend due to circumstances beyond your control). It is important to note that insurance companies do not provide reimbursement for cancelled sessions; thus, you will be responsible for the full fee amount as described above. Brain Solutions reserves the right to suspend services until the fee is paid. Excessive appointment no shows and frequent late arrivals is grounds for discharge from our services. This includes cancellations without the required 24-hour notice. This cancellation policy is standard in most medical and behavioral health practices and will be strictly enforced.

*Patients covered under TXIX/TXXI healthcare benefits are exempt from paying a fee.

In the event that the patient has a payment on an active account, whether through cash, check, credit card or other means, and there remain additional funds available after that account is satisfied (e.g. an overpayment), Brain Solutions PLLC is authorized to apply the overpayment to any other account owed by the patient that remains unpaid. Brain Solutions reserves the right to charge a nominal processing fee for all credit card transactions.

I have read, understand, and agree to adhere to Brain Solutions PLLC's Financial Agreement as stated above.