OFFICE POLICIES AND CONSENT TO TREATMENT
Welcome to my practice.
This sheet contains important information about my professional services, office policies, and our work together. Please read it carefully, and discuss any concerns you may have with me.
RISKS AND BENEFITS
Psychiatric treatment with medications or psychotherapy has both risks and benefits. Risks include experiencing levels of emotional distress including sadness, guilt, anxiety, anger and frustration. Medications themselves each carry individual risks and benefits. Treatment has also shown to have benefits for people who undertake it, leading to relief of feelings of distress, better relationships and resolution of specific problems. There is an expectation but no guarantee that you will benefit from treatment. Medications all carry individual risks, and it is my obligation to discuss in detail these specific risks with you if this is to be part of your treatment.
CONFIDENTIALITY
What we discuss in sessions is confidential and may not be revealed to anyone without your permission except where disclosure is required by law. Disclosure may be required if there is a reasonable concern of
1) abuse or neglect of a child, dependent or elder adult
2) danger of harm to yourself or others
3) grave disability
4) pursuant to legal proceedings
I will not disclose information to your insurance carrier beyond a diagnosis code and a procedure code that is required for your reimbursement. I may ask you to sign a release to coordinate with your other health professionals. I may find it helpful to consult other specialist professionals about your care, in which case no identifying information about you will be revealed and I will discuss this with you first. To protect your privacy, I will discuss with you how you wish to be contacted, what information may be left on voicemails and how you wish to be greeted if we see each other in public.
FEES
Payment is expected at the time of service unless other arrangements are made. If we arrange for monthly billing, payment is expected within one week of receiving your bill. You will receive a monthly invoice reflecting your sessions. This will be in a form suitable for insurance reimbursement or deductions from Health Care Savings Accounts. For your convenience I accept checks, credit cards and cash. If your insurance carrier will pay for a part of your treatment, you are still responsible to pay for services first. You may submit your monthly invoice to your insurance company for them to reimburse you as their policy allows.
MEDICATION REFILL POLICY:
Medications are best managed in an appointment where effectiveness can be assessed and possible side effects can be monitored. We aim to provide enough medication to last until time for the next follow-up appointment. If medications are running low, you may need to contact our office and schedule an appointment with Dr. Calico.
Please allow 1-2 full business days (24-48 hours) for medication refills to be processed. Medication refills are made at the discretion of the doctor and will not be authorized if an appointment is past due. All refill requests are managed at the main office on from Monday- Friday. Medication refills are not managed during the evenings or weekends when the office is closed.
For patients whom are seen predominantly for medication management, it is important to have an appointment in order to renew medication. It is common practice for a psychiatrist to phone in a small supply of medication that will last until the next scheduled visit. I do this to ensure proper evaluation of symptoms and medication response.
CONTROLLED SUBSTANCE POLICY:
Controlled substances require more responsibility from both the patient and the prescriber. *New York State encourages physicians to monitor all controlled substances a patient is prescribed though an electronic registry. If a patient repeatedly loses prescriptions or requests early refills, we must have a conversation about the appropriateness of continuing the medication. Similarly, if a patient obtains a psychiatric controlled substance from another prescriber without alerting me, we may need to discuss the appropriateness of continuing a controlled medication.
(NEW YORK STATE MANDATED PRESCRIPTION MONITORING SYSTEM (I-STOP)
I-STOP is intended to help practitioners better evaluate their patients being treated with controlled substance and was passed to help:
*Prevent prescription drug abuse and overdose
*By better tracking and monitoring prescriptions for controlled substances, drug abuse and overdose can be reduced.
*Prevent prescription fraud
*By moving to a 100% electronic prescription system, paper prescription pads can no longer be stolen, forged, or altered to illegally obtain a prescription drug.
*Prevent prescription errors
*Utilizing modern prescription technology has the potential to minimize medication errors for patients in New York State. Electronic prescribing also allows for the integration of prescription records directly into the patient%u2019s electronic medical record.
*Prevent double doctoring/doctor shopping
*Double doctoring and doctor shopping refer to patients seeking care from multiple physicians simultaneously, often with the intent of receiving additional prescriptions. I-STOP allows providers to more easily access a patient%u2019s prescription history in order to prevent this type of abuse.)
CANCELLATION
The scheduling of an appointment is your reservation of time specifically for us. You will be billed for all scheduled sessions. If you need to cancel an appointment, I require 48 hours advance notice or full fee is billed. I will do my best to reschedule a missed session with you within what our schedules allow. In general, I am not able to conduct a session over the telephone. I cannot treat you adequately without your full attendance at scheduled sessions.
RECORDS
I keep records of your treatment that include times we met, your billing records and indications of medication use and response, in addition to some content of sessions. Any extensive therapy notes belong to me and are generally not privy to the procuring of medical records. I do not give testimony in court. In the unfortunate that you bring suit against me, you waive confidentiality and I am allowed to present my understanding of your case without explicit consent.
VACATIONS
I will tell you my vacation schedule well in advance and will provide you with a physician to contact with emergency issues or matters while I am away. I generally do not charge for missed sessions around major national holidays.
REACHING ME
I do my best to be available by telephone. While I am generally in the office throughout the week, I do not answer the phone if I am with a patient. If you need to leave a non-urgent message about scheduling, please leave a message on my phone and I will do my best to contact you during the day, generally during business hours. If you need to reach me urgently, you may call (347) 218. 2908 to have me paged and I will return your call immediately. Please reserve this for truly urgent matters or emergencies, as it often involves interrupting the session of another patient. There will be no charge for phone calls unless they are unusually lengthy or frequent. In the event routine phone contact is needed, fees will apply. I use email for professional communication and sometimes patients prefer text messaging, but I must inform you it is not a secure form of communication.
ENDING TREATMENT
Usually we decide mutually when to end treatment. However if you decide to leave treatment on your own, you are free to discontinue at any time, but I ask that you please inform me in a timely fashion so that I may open your appointment to someone else. Under the unfortunate circumstance of your non-compliance with scheduled appointment times or non-compliance with agreed upon treatment plans, these too can be grounds for discontinuation of the physician/patient treatment relationship. Should this happen, you will be notified in writing of your discharge from this practice and given options for continued treatment; either in the form of a list of recommended physicians outside of the practice and/or other mental health agencies, such as NY states 1-800-LIFENET, which can aid you in finding continued mental health care services that fit your needs.
LIMITS OF SERVICE
In the event of a life threatening emergency, please call 911 or go to the nearest emergency room. Call me as soon as practical. I do not provide disability, workers compensation or insurance company evaluations. In the event you intend to apply for disability or workers compensation coverage, please discuss this with me first.
Medical doctors are licensed and regulated by the medical board of New York http://www.health.ny.gov/professionals/doctors/conduct/
or 1-800-663-6114.
We may revise this agreement as needed to support our work together.
CONSENT
My decision to undergo treatment is voluntary. I have read and understand the above information and agree to comply with office policies.
Name _______________________________ Signature _______________________________