Privacy in Our Offices  

For the protection of our patients/clients and staff, any activity that may be considered an invasion of privacy while in our offices will discharge the offender from our practice. These activities include, but are not limited to, photography, recording of conversations, or similar behavior. Charges will be fully pressed against the offender of the law. 

Financial Policy  

Full payment of your financial responsibility is due at the time of service. We accept cash, some credit cards, and checks with a valid driver’s license. Suppose your insurance policy requires preauthorization for a service and you do not have that authorization information. In that case, you will be responsible for payment of the total fee at the time of service. If your insurance denies a claim because there is no initial authorization, you are responsible for payment of the entire cost. Payment of Deductibles and Copay/Coinsurance is expected at the time of service. If your account becomes delinquent and is forwarded to an attorney for collection, that patient is responsible for the attorney fees and all court costs. 

Because of our contracts with insurance companies, we cannot provide service without charging you the portion for which you are responsible. You are authorizing Clear Mind, LLC to bill your insurance company directly and receive compensation for services rendered. You are authorizing Clear Mind, LLC to send treatment plans to my Insurance Company and exchange information regarding my treatment. 

All overpayments are credited to your account. They will be held and applied as needed until all services have been paid in full. Remaining overpayments will be applied against future services unless the overpayment is at least $20.00, and you request reimbursement.  

Clear Mind, LLC to send treatment plans to my Insurance Company and exchange information when it pertains to my treatment. 

LIMITS OF CONFIDENTIALITY  

What is discussed in sessions with medication management and/or therapy is kept confidential. No content of sessions will be shared verbally with another party without written consent of the patient or legal guardian. Below is a list of exceptions to confidentiality: 

- Duty to warn and protect: If you disclose a plan or threat to harm yourself, the provider must attempt to notify legal authorities and/or your emergency contact. In addition, if you disclose a plan or threat to harm another person, the provider is required to warn the possible victim and legal authorities.  

- Abuse of children and vulnerable adults: If you disclose, or it is suspected, that there is abuse or harmful neglect of children or vulnerable adults (elderly, disabled/incompetent), the provider must report this information to the appropriate state agency and/or legal authorities.  

- Minors/guardianship: Parents or legal guardians of non-emancipated minor clients have the right to access the client’s records.  

- Insurance providers: Insurance companies and other third-party payers are given information that they request regarding services to the clients. This includes type of services provided, dates/times of service, diagnosis, treatment plan, description of impairment, progress, clinical notes, summaries, etc. 

EMAIL AUTHORIZATION  

I authorize Clear Mind, LLC and its employed and contracted licensed health care providers and staff (collectively, the “Practice”) to use email to communicate clinical information to me about mental health care services that I may receive from the Practice. I acknowledge and understand that the most secure method of communication is by telephone call; however, if I choose to communicate with the Practice by email, these communications may contain my personal and private medical information (including, but not limited to, my name, address, date of birth, types, and dates of mental health care services received, medications, insurance coverage information, and/or test results).  

I understand that although the Practice will take reasonable measures to attempt to protect the privacy of the contents of emails sent to me, the emails sent to me travel over the Internet. As a result, there is a risk that emails may be intercepted and read by unauthorized third parties. I assume this risk by choosing to communicate with the Practice via email.  

I acknowledge and understand the following as it relates to email communications:  

1. Email is inappropriate for conveying information about urgent or emergency medical matters. If I am experiencing an urgent or emergency, I understand that I should dial 911 immediately. 2. If an email has not been answered within twenty-four (24) hours, I should call to ensure that it has been received, and I may make an appointment to discuss the email.  

3. I will not use email communications to discuss sensitive or highly confidential issues. If there are specific types of information that I do not want to be included in emails, I must notify the Practice.  

4. Certain other health care providers who are permitted access to my medical records (such as consulting health care providers) may have access to my email address and email message.  

5. I, and not the Practice, am responsible for the security of emails sent from or stored on my computer, tablet, or phone.  

6. My decision to allow the Practice to communicate with me by email is voluntary, and treatment is not conditioned upon my election to do so.  

7. The Practice or I may stop email communications at any time for any reason.  

8. I agree to notify the Practice when my email address changes.  

9. I will not hold the Practice responsible for damages resulting from its use of email or the failure of any of the Practice’s information systems to facilitate email communications.  

10. I understand that all emails related to my care, received, or generated by the Practice, may be maintained in my medical record.  

INFORMED CONSENT FOR TREATMENT 

I have received the Clear Mind, LLC, Patient Information Packet, which includes information regarding access, fees, Patient Rights and Responsibilities, and Privacy Practices. I accept these policies and practices. I have been allowed to review both "Rights and Responsibilities" and "Privacy Practices. I understand I may request a copy of these notices if I wish to keep them for reference.  

I understand that behavioral health treatment offers no guarantees. By working with my healthcare providers, I should get help with the problems and concerns I bring to Clear Mind, LLC. However, I recognize that things may get worse. I understand that I will probably need to do homework--that is, try new ways of dealing with my problems—which I develop with my healthcare providers. If I do not do these things outside the office, I understand that the effectiveness of treatment will be limited. 

I agree to cooperate fully with my healthcare provider(s) or to discuss any reasons why I cannot. I agree to ask any questions I have to clarify my therapeutic goals and how treatment is addressing them.  

I understand that treatment will end when the problems and concerns I initially had are resolved. I also understand that I can terminate my treatment at any time I wish. I agree to notify my healthcare providers of my intent to end therapy and to discuss the possible risks of premature termination of therapy.  

I also understand that my healthcare provider(s) may end my treatment if we do not progress or if our relationship becomes too strained to continue working together. If I can no longer pay for services and treatment is to be terminated early, my healthcare provider(s) will make suggestions to guide me in finding another provider of my choice. I will make every effort to follow the suggestions. 

TELEHEALTH CONSENT 

Telehealth in General: Telehealth involves the real-time evaluation, diagnosis, consultation on, and treatment of a health care condition using advanced telecommunications technology, including interactive audio & video. Electronic systems have network and software security protocols in place to protect the confidentiality of patients’ information.  

Expected Benefits: Clear Mind, LLC (the “Practice”) offers telehealth services to its patients to improve access to health care by enabling a patient to remain at home (or at a remote site) while receiving care from a distance.  

Potential Risks:  

• In the event of interruption or disconnection of the audio/video connection, the continuity or completion of a particular telehealth visit will depend upon whether the information transmitted is sufficient for the patient’s condition. The Practice may require an in-person visit if the audio/video connection is inadequate for that purpose or is disconnected.  

• Your health information will be transmitted electronically by audio and video. By HIPAA regulations, the Practice has implemented strict privacy and security precautions to protect its patients’ health information; however, the security and confidentiality of information transmitted electronically may be compromised by the failure of these security safeguards or illegal or improper tampering. 

• While the Practice has made reasonable and appropriate efforts to eliminate any confidentiality risks associated with your telehealth appointment, the Practice cannot control your environment or any company you may have with you during the telehealth appointment.  

Medical Records: All existing State and federal laws regarding the privacy and security of your medical records apply to this telehealth appointment, as detailed in the Practice’s Notice of Privacy Practices. By HIPAA, the Practice will not record or store any video, images, or audio of your telehealth appointment. By signing below, you agree not to record or store any video, images, or audio of your telehealth appointment. Your provider will document the medical information conveyed during the appointment into your medical record as if it were an in-person office visit. You have the right to obtain copies of your medical records; any requests to inspect and obtain copies of medical records associated with telehealth will be made by the Practice’s standard policies and procedures.  

Data and Devices. The Practice does not warrant that its telehealth services will be compatible with any updates to, or prior versions of, your devices’ operating systems. To the extent that your telehealth appointment requires wireless, cellular data, or internet access, you are responsible for securing the necessary data access service. E.g., your mobile phone provider may charge you data access fees in connection with your use of telehealth services. You are solely responsible for all such charges payable to third parties.  

Patient Rights: You may withhold or withdraw your consent to telehealth at any time without affecting your right to future care or treatment. You may contact the Practice at 240 932 0920 for any questions related to telehealth services.  

Risks, Consequences, and Benefits: By signing below, you acknowledge that: (i) you have been advised of the potential risks, consequences, and benefits of telehealth; (ii) you have had an opportunity to ask questions about the information presented on this form; and (iii) all your questions have been answered, and you understand the information provided above.  

CONTROLLED SUBSTANCE USE AGREEMENT 

I understand that I/my dependent may be diagnosed with or treated for a medical condition requiring controlled substance medication(s) (benzodiazepines, stimulants, etc.) because this medical condition has not been adequately managed with non-controlled medications, and this medical condition limits my function. I understand that this medication intends to increase my/my dependent’s ability to function, though the controlled substance medication is unlikely to eliminate my/ my dependent’s condition. 

I/my dependent will take the medication only as prescribed. I/my dependent will not accept any additional sedatives, alcohol, or other pain medications without the prior approval of my provider. 

I/my dependent understand that the medication will be prescribed only according to the agreed-upon schedule. Prescriptions will be provided only during regular business hours. Medications will not be called into the pharmacy. 

I/my dependent will not seek or accept any additional controlled substance medications (i.e. pain, anxiety or stimulants) other than those prescribed by my provider. This includes prescriptions from other providers, medications borrowed or accepted from family or friends, and illicit or street drugs. 

Medication refills will be provided as written prescriptions only. No refills will be given before 30 days. I understand that I must make appointments with my provider at least every (3) month or sooner if my provider recommends it. No refills will be given if I do not keep these appointments. Two (2) no-show appointments will constitute grounds for immediate dismissal from the practice. 

I understand that my provider is under no obligation to provide these medications to me and that he/she reserves the right to discontinue these medications at any time. If I refuse, I understand the medications will be stopped. 

I understand that lost or stolen medications will not be refilled under any circumstances. It is my responsibility to protect and secure my medications. This includes keeping the medication out of reach of children. A copy of a police report will be required for any lost or stolen controlled substance prescriptions. 

I understand that my provider may request a specialist evaluation of my treatment, and I agree to keep appointments. My provider will send a copy of my medical record and care to the referred physician. 

I understand that by law, my provider must report all controlled substances dispensed to me to the state-monitored prescription monitoring program. 

TERMINATION OF TREATMENT 

In addition to the above agreements, I accept the right of my provider's staff to terminate this agreement for any of the following reasons: 

a) I seek or obtain any controlled substance(s) from a source other than my provider. b) I in any way attempt to forge or alter a prescription. 

c) I distribute my prescribed medication(s) to any other person. 

d) My medical condition declines to the point at which, in the judgment of my provider, continued therapy with this medication presents a danger to my well-being or safety. 

e) There is evidence that I am no longer receiving an excellent therapeutic benefit from the medication, or my provider determines that I am no longer a good candidate to continue the medication.