Terms and Conditions for Psychiatric Treatment at Red Rocks Psychiatry with Marlene Pino PFMHNP-BC
Welcome to my practice. Your agreement to the following terms and conditions is required for you/your child to receive professional services from me. If you do not agree, I will be glad to give you referrals to other providers.
Clinical services
You consent for yourself/your child to receive a comprehensive diagnostic assessment. At the end of the evaluation, we will mutually decide if we will continue treatment together.
If there is a potential of any physical danger to you, your child, or others, you will call 911 immediately or go to the closest emergency room. I am not reachable outside of regular business hours.
Red Rocks Psychiatry is a Non-Emergency Service; please allow 24 to 48 business hours for all calls and refill requests.
Note I do not have admitting privileges, nor am I affiliated with or on staff at any hospital. Should I deem more intensive services are needed than I can provide, I will do my best to ensure safety and obtain the appropriate level of care, but I cannot provide that care directly and cannot guarantee the receipt or quality of care that others provide.
All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. You are entitled to receive a copy of these records unless I believe that seeing them would be emotionally damaging. If this is the case, I will be happy to provide the records to an appropriate mental health professional of your choice or to prepare an appropriate summary instead. Because client records are professional documents, they can be misinterpreted and can be upsetting. If you wish to see the records, it is best to review them with me so that we can discuss their content.
If you or your child is seeing me for medication management only:
● You will contact your/your child's therapist first for any emergency or crisis, unless it may be medication related
● You will inform me if you/your child are/am considering stopping therapy, or have actually stopped
● You/your child will see me in person no less than every three months for psychiatric medication reassessments.
Risks and benefits of psychotherapy: Psychotherapy has both benefits and risks. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events. Potential benefits include a reduction in feelings of distress, better relationships, better problem-solving and coping skills, and resolution of specific problems. Given the nature of psychotherapy, it remains an inexact science, and no guarantees can be made regarding the outcome.
Psychiatric Medication Management
●Refill requests should be made at least 3 – 5 days in advance of medication running out, Follow up appointments need to be scheduled to coincide with medication refill needs.
●Refill requests will not be processed on nights, holidays or weekends.
●Clients not seen within the appropriate follow up time of three months will not be able to refill psychiatric medications until an in-office or Telepsychiatry (if appropriate) services has been provided.
●While it is not the intent to have you have any lapse in medication; if you have failed to take regular follow up appointments, medication will not be refilled.
Late Shows, No-Shows and Cancellations
●If you are unable to make a scheduled appointment, you can reschedule via email at least 24 hours in advance.
●If you do not show for an appointment and have not provided 24 hour advanced notice, you will be charged in full for the appointment.
●If you show up late for your appointment, you will be able to complete the remainder of your scheduled session. There is no guarantee that you can be accommodated for the missed time, however, you will be charged for the entire scheduled appointment.
●Please note that Mrs. Pino will not wait longer than 10min past the appointed time for TelePsychiatry appointments.
●In case of inclement weather affecting your ability to make your appointment, contact Mrs. Pino by email.
Social Media
●In accordance with American Psychiatric Association Policy, I do not accept friend or contact requests on any social media (e.g. LinkedIn, Facebook).
Emotional Support/Service Animals
●Only officially designated emotional support and/or service animals are allowed inside the building. Please provide written documentation in advance in these circumstances.
●Mrs. Pino does not authorize animals to be emotional support animals.
Confidentiality
There is no guarantee of confidentiality under the following conditions:
●If I suspect you/your child are/is in imminent danger of harm to self or others, or a child or elderly person is being abused or neglected (as I am a mandated reporter)
●If a court orders a release of information
●If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
●If your insurance company requests to review your/your child’s case
●If you pay by credit card, my name will appear on your credit card statement
●If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collections agency or other responsible party
●Between me and my administrative staff, or colleagues with whom I consult professionally
You confirm you have reviewed my HIPAA privacy practices here: RedRocksPsych.com
Payment
You agree to pay professional fees as follows:
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90min Initial Psychiatric Assessment $300
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15-45min Psychiatric reassessment $100-150
For All Insured Clients, I will submit claims on your behalf as a courtesy, but there is no guarantee that your insurance will pay. You are responsible for full payment, whether your insurance company ends up paying partially, or not at all, for services rendered.
● Therefore, you consent to the release of information to third-party payors or their representatives as deemed necessary to determine benefits entitlement and to process payment claims for services provided.
● You authorize and direct that payment of any health insurance or healthcare benefits otherwise payable to you be directly paid to Red Rocks Psychiatry who is authorized to bill in connection to those services provided to you.
● You certify that the information given by you in applying for payment is correct and you acknowledge full responsibility for, and agree to pay, all charges not otherwise paid by your insurance company or other payor.
● Charges are due and payable upon receipt of the bill.
For Sondermind Clients: Sondermind arranges all claims and payments directly with the client.
You agree to pay for any time spent in your or your child's care outside of session time on a prorated basis (unless otherwise detailed below). Unfortunately, insurance companies typically do not reimburse for this. Some examples include but are not limited to:
● No shows/rescheduling with less than 24hrs business hours' notice: full session charge. For example, if you or your child’s appointment is on Monday at 4pm, you will communicate your cancellation no later than the previous Sunday at 4pm; if an appointment is on Tuesday at 10am, you will communicate no later than Monday at 10am.
● Phone calls, messages in the patient portal, voicemails, letters, video sessions and texts between me and: you, your child, or other physicians, therapists, teachers, family members, insurance companies, etc.
● Prescription refills outside of session time
● Time spent obtaining prior authorizations
● Coordination of care for emergencies, hospitalization, intensive outpatient, residential treatment, rehabilitation, etc.
● All forms (insurance, worker’s compensation, school, employer; doctor’s notes, letters, or reports) and chart reviews not filled out in session
● Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority
●You affirm you are an authorized user of the credit card whose number and expiration date supplied, and you do authorize its use for all fees incurred.
You are financially responsible for all charges, whether or not:
● Insurance pays for any services
● We decide to proceed with treatment
● Treatment is successful, for which there cannot be any guarantee
Transfer of Care and Termination
●If you decide to transfer care to another provider or resume care with your primary care provider, please inform Mrs. Pino of this.
●If you have more than 2 no shows or same-day cancellations, you will be asked to complete a treatment contract.
●If you fail to show up for 2 intake appointments, you will be referred to another local provider. You may be charged for canceling within 24 hours or no show.
●Mrs. Pino reserves the right to terminate and transfer care. In these instances, you may be provided with 1 month of medication (if indicated) and a list of local providers.