Effective Date 7/1/2019. Reviewed 10/29/20
PRACTICE AND FINANCIAL POLICIES
Thank you for choosing Alverdia Health!
Our Vision: We are committed to providing you culturally informed quality care.
Working Hours and Communication: Our practice is currently only open on Mondays and Tuesdays. However, we do provide after hours coverage for non-emergent but time sensitive matters.
On the days our practice is closed we endeavor to respond to all queries and communication within 24 (twenty-four) hours.
While we endeavor to respond to all queries (secure communication, voicemails, etc.) as promptly as possible, please note that Alverdia Health DOES NOT provide crisis management or emergency services. Please DO NOT wait for a callback in cases of medical or psychiatric emergencies. Instead, kindly take steps to keep yourself safe by calling 911 or visiting your nearest emergency room.
The stages of treatment are divided into two distinct aspects, namely, assessment and treatment. The first step towards beginning our treatment journey with you is by way of the first three meetings with you. These initial consultations are assessment consultations only and will neither guarantee treatment nor should be considered as treatment. These consultations are utilized to assess if your needs and goals match those of this practice. Receiving literature and information about psychological issues or preliminary consultation at this practice does not imply or guarantee that we have either agreed to treat you or that we can see you in any other setting.
The purpose of this ‘practice and financial policy’ is in anticipation of your questions regarding patient and insurance responsibility for services rendered. We hope this will answer all your questions in this regard.
- Please affix your initials where indicated through this document to confirm that you have read and understood that section.
- Please read through the entire document carefully before affixing your signature at the bottom.
III. REGISTRATION FORMS:
Prior to scheduling an appointment with Alverdia Health, you will need to fill out one or several of the following forms, as may be applicable to you:
- Consent to Evaluate and Treat;
- A signed copy of our Office Practice and Financial Policies form;
- Telepsychiatry Consent Form;
- Acknowledgement of Receipt of HIPPA Privacy Practices;
- Authorization for Credit Card Use;
- Credit card Notice/Approval for no Shows or less than 24 hour’s cancellation.
- Primary Care Waiver form.
- Psychiatry Intake form.
- Patient Health Questionnaire (PHQ 9).
- Generalized Anxiety Disorder 7 (GAD 7).
- Wellness Inventory Scale.
Please fill out these forms completely. Assessment and treatment shall be subject to your filling out all relevant forms applicable to your case.
IV. OTHER TERMS OF OUR POLICY
1. Insurance. We participate in Blue Cross Blue Shield PPA, PPO, Indemnity, Cigna PPO plan, Aetna Health Insurance, Allways Health Partners, Harvard Pilgrim and United Health Care. If you are not insured by a plan we do business with, full payment is expected at each telepsychiatry or office visit. If you are insured by a plan we do business with, but you do not have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. It is your responsibility to be aware of your insurance benefits. Please contact your insurance company with any questions you may have regarding your coverage.
Please also note that while we do provide 24×7 care at our practice, this only includes non-emergent care and treatment, please refer to Section  of this form for more details.
2. Co-payments and deductibles. All co-payments, deductibles and/or co-insurance (“Co-Payments”) must be paid at the time of service. We reserve the right to automatically deducted all payments due from the credit/debit card we have on file for you in case of your failure to pay any such charges. Co-Payments of this nature are part of your contract with your insurance company and any failure on our part to collect Co-Payments from patients can be construed to be fraud. Please help us in upholding applicable legal and contractual obligations by paying your Co-payments at each visit.
3. For self-pay, out of Network and Non-covered services. We bill our service by time in function of our hourly rates. The applicable rates in this regard are as follows:
|1.||Initial psychiatric evaluation up to 60 minutes||$300|
|2.||Initial psychiatric evaluation more than 60 minutes and up to 75 minutes||$375|
|3.||Psychopharmacology follow-up up to 30 minutes||$150|
|4.||Psychotherapy follow-up more than 30 minutes and up to 45 minutes||$225|
4. Non Prior Authorization Requests: To encourage our patients make great use of their appointment and/or provider’s clinical time to address their concern(s) or request(s), except for prior authorization request, all communication via the patient portal, telephone or email outside their provider(s)’ clinical hours will be billed by time in function of our hourly rates.
5. Outside Hours Medication Refill Requests: All medication(s) refill requests outside of the provider clinical hours at Alverdia Health will be billed by time in function of our hourly rate.
6. Request for hard copies of Medical Record : All requests shall be billed as follows:
- Processing Fee: $15.00
- Pages 1 – 100: $0.50 per page
- Pages 100+: $0.25 per page via fax or mail.
All charges are non-refundable. Please note, in accordance to the Cures Act, that your electronic medical record is freely accessible via the portal.
7. Incomplete Forms: All requests to complete forms that cannot be completed during a session, for reasons not attributable to us, will be billed by time in function of our hourly rates.
8. Change in Fees: All updates regarding any change in our fees will be periodically posted on our website.
9. Telepsychiatry visits: Videoconference calls may be made between 2 minutes prior up to 15 minutes after to your scheduled appointment time. Please be prepared during this time to receive such calls and to begin sessions in a timely manner. Your failure to be available on the videoconference call 15 minutes after your scheduled appointment time may require us to re-schedule your session and to treat the session you failed to appear at as a ‘no-show’. You will be billed for all ‘no-show’ sessions according to our policy. Details are at clause 12 below.
10. Financial Responsibility.* I understand that my health insurance coverage may have certain restrictions and/or limitations, such as authorization requirements, non-covered services, Co-Payment requirements etc. I agree and undertake to be solely financially liable for any and all related charges in respect of the services I avail at Alverdia Health, where such services or parts thereof are not covered by my insurance. It is my responsibility to understand my insurance benefits and coverage.
11. Payments: Payments can be made by way of cash, check, Visa, Mastercard, Discover and American Express. We can also process your Health Savings Account and Flexible Spending Account.
12. No-shows and late cancellation less than 24 hours will be billed at $50.* We take ‘no-shows’ and cancellation of appointments without notice very seriously, as each time a patient misses an appointment without providing proper notice, another patient is prevented from receiving care. Unless the appointment can be rescheduled for the same day (for either an office or telepsychiatry visit), these charges will apply to all ‘no-shows’ and cancellations without adequate notice. You understand and provide consent for these charges to be automatically deducted from your card that we have on file as on the day of your missed appointment.
It is highlighted that the telepsychiatry sessions while they can be undertaken remotely, cannot be provided if you are physically located outside the State of Massachusetts on account of medical licensing laws that prohibit us from practicing outside the State of Massachusetts. All telepsychiatry sessions, where you are detected to be located outside the State of Massachusetts will need to be re-scheduled for when you are back in the State. The same charges, as above, shall be applicable to all such sessions missed or re-scheduled due to this reason.
Please help us to serve you better by keeping your regularly scheduled appointment. Any balance accumulated because of a missed appointment fees will need to be paid before scheduling another appointment.
13. Termination: Treatment and therapeutic alliance are seen as ongoing and cumulative; if you have not contacted this office in 3 (three) calendar months, we will send you an Outreach notice, which will provide you with a further 30 (thirty) days to follow-up with us. Upon the expiry of this 30 (thirty) day period, it will be deemed that you are no longer interested in follow-up care and/or are having your needs met elsewhere.
You have the right to terminate your care with us by way of either prior written or verbal notice at anytime with or without any reason. It is not mandated but we request, where possible, that you provide us with some form of reasonable notice prior to the date of termination.
We are entitled to terminate our relationship with you forthwith and without notice due to any of the following reasons:
- Excessive late cancellations – where the term ‘excessive’ shall means such number as we may deem to be excessive at our sole discretion; or
- After 3 No-shows within a 12 month period; or
- Your failure to disclose information required by us or the declaration of any false or misleading information by you; or violation of any of our office policies; or
- Your failure to respond to our communications in a timely manner, as determined by us; or
- Abuse or violence by you in regard to any facilities or infrastructure, members of staff, other professionals or other patients receiving treatment at our facilities; or
- Your failure to pay for any services at any time whatsoever; or
- symptom acuity beyond what can safely be managed, solely in our opinion, in this setting; or
- differences in opinion over treatment methodologies and goals; or
- using interventions that may be classified, at our sole discretion, as non-prescribed, dangerous or against-medical-advice; or
- any other similar concerns not expressly covered herein.
14. Standard of Care & Evidence Based Practice: Some treatment and care recommendations discussed with you may not be considered first-line, recommended by the FDA, and/or consistent with the general community standard of care.
We will you keep you informed and updated at all times should we decide to deviate from the standard of care or approved indications, of the evidence basis, effects in persons with similar symptoms or history, associated risks, benefits, side effects and alternatives as well as standard-of-care recommendations for such therapies.
15. Medications: Medication will not be prescribed to patients located outside the state of Massachusetts.
Controlled or DEA-scheduled medications (Schedule II, III, IV, V etc.) will not be issued to new patients seen via telepsychiatry.
At Alverdia Health, we strongly believe that controlled substances are best used sparingly, carefully, and only for a very limited amount of time. When used for prolonged periods, controlled substances may become addictive and foster dependency or safety concerns. At our practice, we prefer the implementation of psychotherapy, positive lifestyle changes, and the administration of non-addictive medications to best address the needs of our patients.
Please note that as a general policy Alverdia Health does not prescribe substance abuse treatments like suboxone, methadone etc. Our practice also refrains from the prescription of benzodiazepines. Psychostimulants are only prescribed for ADHD, for patients seen at least once in person, when we are able to review and determine ADHD from the results of a recently completed comprehensive neuropsychological report.
Prior to prescribing a controlled-substance we will discuss and have you sign our controlled substance agreement. Our prescription monitoring program is supervised carefully and on a regular schedule. Patients found to be abusing controlled substances will be discharged from Alverdia Health.
16. Proof of insurance. All patients are required to complete our patient information requirements via our online patient portal at least 24 (twenty-four) hours before seeing a care provider. We must be provided with a copy of your valid driver’s license and (if applicable) current valid and subsisting insurance card or policy as proof of insurance. Your failure to provide us with the correct insurance information in a timely manner may result in your being billed for the balance of the claim.
17. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly to us to facilitate this process. It is your responsibility to comply with the request of your insurance company. Please be aware that the balance of your claim is your responsibility and whether or not your insurance company pays your claim you continue to remain liable towards all such payments. Your insurance benefit is a contract between you and your insurance company and we play no role in how these claims are processed or settled.
18. Coverage. If your insurance policy or provider changes, please notify us prior to your next visit so we can make the appropriate changes and accommodations to help you receive maximum benefits under the new policy/coverage.
The failure of your insurance company to pay your claim within 45 (forty five) days will make you liable to pay all balances due and payable. You will be notified of such balances and the appropriate amounts shall be deducted from your card on file with us.
To prevent and evade any lapses or delay in your care, please also make sure that you keep your insurance information up to date at all times along with your contact information (change of address name, etc..) on our patient portal.
19. Nonpayment. If your account is over 30 (thirty) days past due, you will receive a letter stating that you have a further 20 (twenty) days to clear all balances outstanding against your account. Please be aware that if this balance remains unpaid beyond this period, we reserve the right to refer your account to a collection agency or to take such further action for recovery as we may deem appropriate, including but not limited to formal legal action against you, further, you may be discharged from our practice for any delinquency in payment beyond these prescribed periods. In case you are discharged from our practice, you will be notified by regular and certified mail that you have 30 (thirty) days to find alternate mental health care services. During that 30 (thirty) day period, our care providers will be able to treat you in respect of urgent matters only.
20. Credit card on file. Our policy with regards to cancellation without notice and no-show for appointments, as discussed in detail hereinabove at clause 12, is to charge $50 in this regard. To enable us to have the protection of the ‘no-show’ charges as well as the settlement of other dues that might be payable but unpaid from your end, we request that you submit a current credit card on file prior to your first visit. In case you have not submitted your payment information at least 24 (twenty-four) hours prior to the time of your scheduled appointment, your session may be rescheduled, and you shall be considered a “no-show” and billed according to our ‘no-show’ policy.
21. Intake/Consent Form: Please submit all required paperwork and consent forms within 48 (forty) hours of receipt. If you have not returned the required paperwork by this time, you will not be able to schedule an appointment.
22. Practice focus: Our practice focus on the treatment of acute mild to moderate anxiety, depression, burn-out and life stressors. In the same way that a doctor’s office is different from an Emergency Room, Alverdia Health is a small practice that is not equipped to treat conditions that require urgent and immediate care. Alverdia Health DOES NOT treat psychotic disorders, personality disorders, addictions, severe eating disorders, or ongoing suicidality, dementia or other psychiatric emergencies. If you experience any of these symptoms during the course of our treatment we will refer you to the appropriate specialty or level of care with an external service provider, in which regard we disclaim all liability. Such third-party service provider may have their own policies and procedures, which you may be required to comply with to receive treatment.
Please note that at this time, Alverdia Health is unable to accept patients with any form of Medicare or Medicaid. If during the course of treatment you become a ‘Medicare patient’ or ‘Medicaid patient’, you will need to find a new mental health provider that accepts your insurance.
23. Appointment/refill request: Please note that outside your clinical appointment time, you can schedule, re-schedule or cancel your appointment directly through our website. All requests for medication refill(s) are mandated to be made only through the online patient portal.
24. Patient Portal. Alverdia Health, in partnership with IntakeQ (our electronic charting system), offers a Patient Portal (PHR) for the exclusive use and convenience of our registered patients. The Patient Portal is designed to enhance patient–provider communication and allow patients to be more involved in their care. The Patient Portal provides secure access to the following services: appointment scheduling, secure messaging, and ability to view and download your health records. Please note that all email or Patient Portal communication is part of the medical record.
Permissible purposes for Patient Portal Communication
|Prescriptions renewals||Urgent or time-sensitive information|
|Scheduling Appointments||Confidential information on symptoms or lab results|
|Brief non-clinical Updates, such as|
“Started new medication, doing well.”
|Complex clinical or concerns that require multiple emails|
The Patient Portal record may not be considered an acceptable substitute for certified records from Alverdia Health for legal proceedings.
It is also recorded that while we maintain commercially reasonable and industry appropriate standards of online security, like all online systems, the Patient Portal may be subject to hacking or similar attacks that may cause data loss or the failure of the portal to function in the manner envisioned. Such events are outside the reasonable control of Alverdia Health and we disclaim all liability in this regard.
PLEASE NOTE: Communication through the Patient Portal does not replace a psychiatric appointment. It should not be used to communicate regarding urgent matters. Time sensitive matters MUST be handled by either contacting your provider directly or by contacting the covering provider. Please note that Alverdia Health does not provide crisis management or emergency psychiatric services. If you are experiencing a crisis, a medical or psychiatric emergency we recommend that you go directly to the nearest emergency room or call 911.
The user agrees to take steps to keep online communications to and from us confidential. This includes, but is not limited to, using only personal devices to access the patient’s records, keeping password information private and inaccessible to third parties, and using a screen saver to prevent open messages from being viewed by others. Please note that it is the user’s responsibility to maintain a current and valid email address that is associated with the patient portal.
If the user identifies any discrepancy in the records, the user should notify us immediately by using the Patient portal messaging system to notify our office.
Additionally, by using the Patient Portal, the user agrees to provide factual and correct information. If abuse or negligent usage of the Patient Portal occurs, we reserve the right, at our discretion, to terminate, suspend user access, and/or modify services available through the Patient Portal. Please read our HIPAA Notice of Privacy Practices for information on how protected health information (PHI) is used at Alverdia Health.
25. Electronic Communication: At Alverdia Health, we only use IntakeQ secure messaging service to directly communicate with patients. If we receive an electronic communication from you through another medium, we would respond via our secure Patient Portal or we will call you to follow-up through our HIPPA compliant telephone system.
Appointment reminders are sent by email, but you can opt out if you do not wish to receive them or prefer a different method of notification. Your decision to utilize potentially insecure electronic services implies your consent to whatever privacy and confidentiality standards may be in place for the services that you choose to use. Phrased another way, we cannot be responsible for the loss or interception of information if your email is hacked, mail is stolen from your mailbox, your computer gets a virus, etc., as this is out of our control.
26. 24 hour coverage: We provide coverage to our patients on a 24 hour/7 day basis. Please note that these services are only provided in respect of non-emergent matters. For any time sensitive non-emergent clinical matters, please contact your provider directly or call our office at 617-300-0728 to leave a voicemail. However if you are experiencing a crisis, a medical or psychiatric emergency we recommend that you visit your nearest ER or call 911 for more appropriate care.
27. Prescription expiration: When your prescription expires, you are required to schedule an office visit in order for us to renew your prescription. Please allow 72 (seventy-two) hours for refills on all medications. We do not accept faxed refill requests from ANY pharmacy. It is the patient’s responsibility to call the office.
28. Primary care: We believe in the importance of a truly whole-person approach to health care. In line with that philosophy, we require that all our patients have an ongoing relationship with a local primary care provider and that we are authorized by you to collaborate with your primary care provider to facilitate your care. You will need to provide a signed release for us to communicate with your primary care provider when you submit your initial patient paperwork. You are responsible for letting our office know if you change primary care providers in the future and complete an updated release.
29 Outside mental health provider(s): We believe if you have outside mental health provider(s) it is important that we have their contact information to help better manage your care. We require for that reason that all our patients authorize us to collaborate with their outside mental health provider(s). We also require your authorization to obtain your past mental health records.
30. Legal Testimony. In our experience, legal matters requiring the testimony of a mental health professional can arise from time to time. This, however, can be damaging to the relationship between a patient and his/her provider. As such, we generally recommend that you hire an independent forensic mental health professional for such services. However, if you become involved in a legal matter that requires our assistance, you will be expected to pay for the Behavioral Health provider’s time, even if called to testify by a third-party. You will be billed directly for these fees as this is not covered by your insurance. We bill an increased hourly rate for work involving legal matters. An advance deposit towards 5 (five) hours services is required and renewable as needed to cover costs and time, included and not limited, for preparation, communications, travel and attendance.
31. Release of information. Any release of patient information requires a completed and signed Release of Patient information form.
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