Appointments

1. I understand this outpatient clinic is by appointment only depending on provider availability.           □ Yes
2. I understand that due to individual state licensing requirements, I must be physically located in the same state in which my provider is licensed at the time of my appointment. If I am not in the same state as my provider, I will be required to reschedule my appointment and be responsible for a late cancellation fee of $25.00, charged to my debit/credit card on file as outlined in the "Payment" section below.                                                                                                                                                 □ Yes
3. I understand appointments are conducted either in person or by video using a HIP AA secure platform. I understand it is my responsibility to ensure my equipment is functioning properly prior to my appointment. I understand if l am unable to join the video appointment, I will be required to reschedule my appointment and be responsible for a late cancellation fee of $25.00, charged to my debit/credit card on file as outlined in the “Payment" section below.                                                                    □ Yes
4. If my appointment is conducted by video, I understand even though the platform is a HIP AA secure platform, there is still a risk for breach of personal and protected health information and will hold the provider harmless of any legal responsibility if a breach occurs.                                                      □ Yes
5. I understand it is my responsibility to ensure my video appointments are conducted in a private, safe, and secure manner without distractions or any other individuals present unless it is a child/adolescent appointment or prior discussion was held with the provider. If this policy is violated, the provider may require me to only attend in person appointments. I understand no other activities or driving is allowed during video appointments.                                                                                                                □ Yes
6. I understand I am expected to schedule my next appointment at the end of my current appointment unless other arrangements have been made with the provider.                                                        □ Yes
7. I understand if I am prescribed medications during my appointment, my provider will send enough medication(s) to my preferred pharmacy to get me to the next scheduled appointment (unless medication adjustments are occurring). I understand if l am at risk of running out of medication(s) prior to my next appointment, I will request medication refills at least 3 business days prior to my medication running out.                                                                                                                                        □ Yes

Appointment Cancellations, Reschedule Requests, Late Arrival or No Shows

1. I understand I will be charged $25.00 using my debit/credit card on file for a late appointment cancellation or rescheduling request, which is deemed as occurring less than 24-hours of scheduled appointment time, or for a no-show appointment, including if I am more than 15-minutes late for my appointment requiring the need to reschedule. Charges are the out-of-pocket expense and responsibility of the patient as health insurance carriers do not cover these charges. Emergency exceptions are considered.                                                                                                                □ Yes
2. I understand the $25.00 late cancellation, arrival (requiring appointment rescheduling), or reschedule request fee/charge applies to same day appointment reschedules. Emergency exceptions are considered.                                                                                                                                         □ Yes
3. I understand all late cancellation, arrival, and reschedule requests, or no-show fees/charges are to be paid prior to being seen at a future appointment.                                                                               □ Yes
4. I understand if an emergency arises such as sudden illness, injury, or hospitalization, it is my responsibility to personally, or someone acting on my behalf, to notify the provider's office immediately. All late cancellation or reschedule requests, or no-show fees/charges will be waived if policy is followed.                                                                                                                                             □ Yes
5. I understand providers may experience illness or emergencies. If my provider is not able to attend the appointment due to such circumstances, someone from the office will contact me as soon as possible to reschedule my appointment.                                                                                                          □ Yes

Communication Outside of Appointments

1. I understand the patient portal is not currently used for communication with the provider, only to receive information such as appointment reminders, screening forms for completion, intake documents for completion, and other important information from the provider. I understand the patient portal should NOT be used to make emergency/urgent requests or to discuss ANY concerns, requests, or needs as the portal is not monitored for patient communication. I understand I am to either phone or text the provider via the appropriate contact numbers with any questions, concerns, or requests.

I understand that if I am experiencing an emergency or urgent situation, I am to IMMEDIATELY call 911 or 988 (Suicide and Crisis Lifeline) or go to the nearest hospital emergency department. ***This includes thoughts of suicide or thoughts of harming oneself or others. psychiatric emergencies, life-threatening emergencies, and medication side effects causing symptoms including, but limited to, chest pain or other heart problems, shortness of breath, moderate/severe rashes, hives, decreased mental alertness, changes in cognitive status, dizziness, lightheadedness, passing out or feeling like you could pass out, or loss of motor control/ability. ***                                            □ Yes

2. I understand to allow the provider up to 3 business days to respond to all non-urgent voicemails and text messages including, but not limited to, medication refill requests and appointment reschedule requests.                                                                                                                                            □ Yes

Payment

1. I understand that this section is a BRIEF overview of payment policies and is in no way all inclusive. A fee schedule is provided to each patient/client at the time of the initial visit and posted if changes occur.                                                                                                                                                             □ Yes
2. I understand it is the policy of Elite Mental Health & Wellness, LLC, to collect all appointment fees including, but not limited to, co-pays, out-of-pocket fees/charges, and any outstanding patient account balances PRIOR to rendering services to the patient/client. I understand I may pay any fee/charges or outstanding account balances via the portal prior to my appointment.                                              □ Yes
3. I understand all outstanding balances including co-pays will be automatically charged to my debit/credit card on file if not paid by the end of the business day (4:00 PM) on the day of the appointment.     □ Yes
4. I understand I am responsible for all fees/charges not covered by my health insurance carrier/plan.                                                                                                                                                                   □ Yes
5. I understand it is my responsibility to be knowledgeable regarding my health insurance eligibility and benefits including, but not limited to, co-pays, deductibles, and out-of-pocket payment requirements. I understand it is my responsibility to determine my health insurance plans eligibility and benefits for all fees/charges. I understand my health insurance coverage may have certain restrictions and limitations, such as, but not limited to, authorization requirements (including for medications), non-covered services such as services provided through video appointments, co-pays, deductibles, co-insurance(s), laboratory tests, and electrocardiograms (EKGs, ECGs).                                                                  □ Yes
6. If you are planning to apply for disability benefits, please know that a minimum of 6 months of care is required before documents are released to the requesting agency/yourself. This is necessary for the provider to be able to provide accurate/thorough information. I understand I may be charged a $100 minimum fee for the first 1-hour and $50 for each additional hour thereafter for any requested forms, letters, or other documents that are asked of the provider to complete outside of normal appointment time. I understand all such requests and paperwork should be completed during appointment time to ensure correct and adequate information is obtained and included. I understand I may request an appointment for paperwork requests/completion. I understand to allow my provider a minimum of 30-business days to complete all document requests to be completed. I understand the fees/charges are my responsibility. Exceptions may apply, which should be discussed with the provider.                   □ Yes
7. I understand unless a payment plan has been arranged between the patient/client and provider, all outstanding patient/client account balances not paid within 90-days of service date may be turned over to a third-party collection agency or small claims court. If the patient/client account is submitted to a collection agency, a 40% collection fee shall be added to the unpaid patient/client account balance upon submission to the collection agency. I agree by signing this form that I agree to this additional fee/charge.                                                                                                                                         □ Yes

Debit Card/Credit Card on File Requirement

1. I understand this section is a BRIEF overview of the requirement for the patient/client to have a debit/credit card on file. I understand that I can obtain more detailed information regarding this policy by discussing it with the provider.                                                                                                           □ Yes
2. I understand it is my responsibility to always maintain a valid debit/credit card on file. I may have a Health Savings Account (HSA) card on file in lieu of a debit/credit card upon agreement with the provider. I understand the card information will be saved for future transactions.                             □ Yes
3. I understand that my card on file will NOT be charged without my permission EXCEPT in the following cases:

     a) Co-pays (for any co-pay not paid by 4:00 PM on the day the service was rendered).

     b) Outstanding account balances (for any outstanding account balance that is not paid by 4:00 PM on the day the service was rendered).

     c) Late cancellation/reschedule and late arrivals requiring appointment rescheduling fees/charges.

     d) No-show appointments.

     e) Past due balances greater than 21-days old and remaining after receiving the Explanation of Benefits (EOB) from the patient’s/client’s health insurance carrier; past due balances the result of service fees/charges not covered by the patient's/client’s health insurance policy.

     f) All outstanding patient/client account balances at the termination of services.                               □ Yes

4. I understand if my card on file is unable to be charged on two or more occasions in a calendar year due to invalid card details, card expiration, insufficient funds, or other issues, I may be required to maintain a credit on my account at the discretion of the provider.                                                                    □ Yes

Termination of Treatment

1. I understand I may be discharged from treatment for failure to comply with office policies and procedures, for exhibiting aggressive behaviors toward provider(s), other staff, or other patients/clients, for unpaid account balances after 60-days, or for noncompliance with treatment plan(s) or appointments. After two consecutive or three in a calendar year late cancellation, arrival, or reschedule appointments, or no-show appointments, I may be terminated from services unless there were extenuating circumstances that the provider accepted.                                                                     □ Yes
2. I understand treatment/services may be terminated at the discretion of the provider if the provider determines there is not an effective therapeutic relationship benefiting the patient/client. The provider may assist the patient/client in locating a new provider if asked to do so by the patient/client.         □ Yes
3. I understand I must have an appointment with the provider at a minimum of every 90-days to be considered in active treatment. I understand I must remain in active treatment for ongoing care, which includes medication refills. Exceptions may occur at the discretion of the provider.                          □ Yes
4. I understand if treatment is terminated for any reason, I may contact Elite Mental Health & Wellness, LLC, to inquire about re-establishing services. I understand that re-establishing services is at the discretion of the provider.                                                                                                                   □ Yes

Social Media

1. I understand my provider does not accept friend or contact requests from current or former patients/clients on any social media network sites. Adding a patient/client as a friend or contact can compromise the confidentiality and privacy of both the patient/client and the provider as well as blur the boundaries of the professional relationship. Any attempt by a patient/client to surreptitiously gain access to the provider's personal social media accounts/sites shall be cause for patient/client termination from services.                                                                                                                                             □ Yes

Signature of Patient/Client or Authorized Representative                                                                                                                                                                                                                                                      Relationship to Patient (if applicable)                                                                            Date