Welcome to our practice. The following information pertains to our practice policies. Please read carefully and let us know if you have any questions that we can answer and discuss with you. We look forward to working with you and providing you with the highest quality of care. When you sign this document, you are agreeing to and acknowledging these policies.

Sessions

The initial comprehensive evaluation is 90 minutes in length. During this session, I will take the time to get to know you and understand your specific concerns and treatment goals. At the end of the session, I will provide you with my assessment and work with you to develop a treatment plan that best meets your needs. This may entail psychotherapy (talk therapy), medication management, education or a combination of these. Some patients may benefit from a longer evaluation process of additional 1-2 sessions before a specific treatment plan can be recommended. If you are seeing another therapist, I can provide medication management and coordinate care with your therapist. Please complete the release of information form at the end of this document for any providers that you would like me to have contact with (eg, primary care physician, therapist, etc).

If medications are initiated, follow up appointments are required as long as medications are being prescribed. The frequency of these follow up appointments vary depending on response to medications, severity of illness and side effects. Medication management appointments are 25 minutes in length.

Cancellations and No-Shows

Your appointment time is reserved for you. Therefore, if you are not able to keep your appointment time, please call as soon as possible to cancel or reschedule your appointment. If you do not provide at least 24 hours’ notice of your cancelled appointment or if you fail to show for your appointment, you will be charged for the full cost of the session. Please call by Friday at 1 pm for any cancellations the following Monday.

If multiple appointments are missed without notice, we reserve the right to terminate treatment and you may be discharged from our practice.

Maintaining Regular Follow Up Appointments/No Contact Policy:

Regular follow up appointments are an important part of your care and a necessary requirement to stay in my practice. If you have not had contact with our office in 6 months, you will no longer be an active patient and will be considered discharged from our practice. Return to our practice after discharge may require a new evaluation or longer return follow up appointment. It will be at our discretion if you are able to return to our practice.

Contacting Me:

I have a full time office assistant that will answer calls during business hours Monday through Friday. I will return urgent calls as soon as possible. Routine calls will be answered within 24-48 hours with the exception of weekends and holidays. If you are experiencing an emergency and cannot wait to reach me, you should call 911 or go to the nearest emergency room. As soon as you are able to do so, please contact me to inform me of the situation.

Calls under 10 mins will not be charged. Calls over 15 mins will be charged at my hourly rate of $350 and will be prorated.

Fees for Services

My fee for the initial comprehensive evaluation is $475. My fee is $350 for 55 minute therapy sessions (with or without medication management) 25 minute medication management appointments are $200. Extended 60 minute follow up appointments are $350. I accept cash, check and credit cards. Please make checks payable to Dr. Dana Reid, LLC

Letters/Forms

Please try to bring forms that need to be completed with you to appointments if possible. For forms/letters that are completed outside of sessions there will be a charge depending on the time spent and extent of the letter/form. The fee will range from $25-100.

By signing this you are confirming that you understand that it is your financial responsibility for services provided. I am considered an out of network provider for all insurance companies. If you have insurance and wish to be reimbursed, I can provide you with a superbill at the end of your appointment so you can file with your insurance. It is your responsibility to file with your insurance company. I do NOT bill your insurance company directly. All reimbursement you obtain from your insurance company is yours.

By signing this form, you consent to have a valid credit card on file with our office at all times while you are considered an active patient. All cards are stored in a PCI secure environment where you card data is "tokenized" for additional security. By signing this form, you are authorizing our office to charge your credit card on file for all appointments including missed or no-show appointments based on our cancelation policies.

By signing this you are confirming that you understand that you will be charged for missed appointments and cancellations with less than 24 hours’ notice. Your appointment is reserved for you. If you need to cancel an appointment, please notify me as soon as possible. Appointments not cancelled with at least 24 hours’ notice will be billed at the full cost of the appointment which is $350 for 55 minutes therapy sessions, $350 for extended follow up sessions and $200 for 25 minute medication management sessions.

Full payment is due at the time service is rendered. I acknowledge responsibility for all fees incurred. Any balances due, will need to be paid in full prior to scheduling an appointment. All balances 30 days past due will be deemed delinquent. Delinquent accounts must be paid in full before any future services will be provided.

Statement of Confidentiality: Under Georgia law communications between patients and psychiatrists are confidential, and under ordinary circumstances this privilege can be waived only by the patient. However, there are three clear exceptions in which a psychiatrist is legally and ethically bound to break confidentiality: (1) the patient is imminently dangerous to him or herself, (2) the patient is imminently dangerous to others and/or has made specific threats to harm an identifiable third person, (3) actual or suspected incidents of child abuse. Although legally and ethically bound to break confidentiality under the aforementioned circumstances, I will not do so without attempting to discuss it with you first.

I have read and understand the above policies.

1. Notify me if there are any significant changes in your psychiatric or medical condition, or if an outside provider changes your medication regimen.

2. Notify me if you suspect or know that you are pregnant or plan to become pregnant in the near future. Pregnancy may affect treatment recommendations

3. If you feel you are at risk of hurting yourself or others, notify me immediately. If you feel you are an imminent risk and need immediate attention, call 911 or go to your nearest emergency room.

4. We welcome emails for non-urgent, administrative communication. Please note that the confidentiality of your email cannot be guaranteed. To discuss medical concerns, please call me.

5. If your medication makes you drowsy or slows your reaction time, refrain from driving and notify me. Also, notify me if your medication causes you other significant side effects.

6. If you want to increase, decrease, or discontinue your medication regimen, call first. Medication management is a collaborative process. Changes without consultation are potentially dangerous and may interfere with our ability to work together.

I have read and understand the preceding Points to Remember.

 

If one of our doctors is prescribing medications to you as part of your treatment, regular follow up visits with them are required to closely monitor for efficacy, safety and potential side effects. Medication management requires working together to ensure the best response to medications. This includes maintaining scheduled follow up appointments.

• You will be prescribed enough medication to last until your next follow - up appointment. Please allow 2 days for medication refill requests if you need a refill. Prescriptions will not be called in for patients that cancel/ or miss regularly scheduled medication follow-up appointments.
   
• If you have to reschedule an appointment, please ensure that you schedule another appointment before you run out of medication. Our office will do our best to reschedule you, but keep in mind it may take several days to weeks to find an appointment that will be conducive to your schedule.  It is your responsibility to make sure you do not run out of medicine.
   

Our doctors are committed to providing professional services of the highest quality and standards. In order to serve our patients efficiently and responsibly, we require agreements be made as to the policies stated above. Patients are encouraged to ask questions before signing.

I have read the medication policies, understand and agree with them.

 

Please complete this form if you would like us to coordinate care with your doctors and therapists. We may send a letter or call your doctor or therapist informing them of your visit and care. You can include any therapists, primary care physicians and other specialists.

Note: This page is optional.

I hereby authorize Dr. Dana Reid LLC to release/obtain information from my medical records as described below to the following provider:

The release will expire in 12 months unless specified by you.

I understand that I can cancel this authorization at any time, except for action that has already been taken.

THIS NOTICE IS FOR YOUR RECORDS

GEORGIA HIPAA NOTICE

Notice of Psychiatrist’s Policies and Practices to Protect the Privacy of Your Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) and Georgia State Laws

THIS NOTICE DESCRIBES HOW PSYCHOLOGICAL AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION UNDER THE NEW HIPAA LAWS. PLEASE REVIEW IT CAREFULLY.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

I may use or disclose your protected health information (PHI), for treatment, payment, and health care operations purposes with your consent. To help clarify these terms, here are some definitions:

• “PHI” refers to information in your health record that could identify you.
• “Treatment, Payment and Health Care Operations” is when I provide, coordinate or manage your health care and other services related to your health care. An example of treatment would be when I consult with another healthcare provider, such as your family physician, psychiatrist or another psychologist.
• “Payment” is when I obtain reimbursement for your healthcare. Examples of payment are when I disclose your PHI to your health insurer to obtain reimbursement for your health care or to determine eligibility or coverage.
• “HealthCare Operations” are activities that relate to the performance and operation of my practice. Examples of healthcare operations are quality assessment and improvement activities, business-related matters such as audits and administrative services, and case management and care coordination.
• “Use” applies only to activities within my office such as sharing, employing, applying, utilizing, examining, and analyzing information that identifies you.
• “Disclosure” applies to activities outside of my office such as releasing, transferring, or providing access to information about you to other parties.

II. Uses and Disclosures Requiring Authorization

I may use or disclose PHI for purposes outside of treatment, payment, or healthcare operations when your appropriate authorization is obtained. An “authorization” is written permission above and beyond the general consent that permits only specific disclosures. In those instances when I am asked for information for purposes outside of treatment, payment or healthcare operations, I will obtain an authorization from you before releasing this information. I will also need to obtain an authorization before releasing your Psychotherapy Notes. “Psychotherapy Notes” are notes I have made about our conversation during a private, group, joint, or family counseling session, which I have kept separate from the rest of your medical record. These notes are given a greater degree of
protection than PHI.

You may revoke all such authorizations at any time, provided each revocation is in writing. You may not revoke an authorization to the extent that (1) I have relied on that authorization; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, law provides the insurer the right to contest the claim under the policy.

III. Uses and Disclosures with Neither Consent nor Authorization

I may use or disclose PHI without your consent or authorization in the following circumstances:

• Serious Threat to Health or Safety – If I determine, or pursuant to the standards of my profession should determine, that you present a serious danger of violence to yourself or another, I may disclose information in order to provide protection against danger for you or the intended victim.
• Child Abuse – If I have reasonable cause to believe that a child has been abused, I must report that belief to the appropriate authority.
• Adult and Domestic Abuse – If I have reasonable cause to believe that a disabled adult or elder person has had a physical injury or injuries inflicted upon such disabled adult or elder person, other than by accidental means, or has been neglected or exploited, I must report that belief to the appropriate authority.
• Health Oversight – If I am the subject of an inquiry by the Georgia Board of Medical Examiners, I may be required to disclose protected health information regarding you in proceedings before the Board.
• Judicial or Administrative Proceedings – If you are involved in a court proceeding and a request is made about the professional services I provided you or the records thereof, such information is privileged under state law, and I will not release information without your written consent or a court order. The privilege does not apply when you are being evaluated for a third party or where the evaluation is court ordered. You will be informed in advance if this is the case.
• Worker’s Compensation – I may disclose protected health information regarding you as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs, established by law, that provide benefits for work-related injuries or illness without regard to fault.

IV. Patient’s Rights and Psychiatrist’s Duties

Patient’s Rights:

• Right to Request Restrictions – You have the right to request restrictions on certain uses and disclosures of protected health information. However, I am not required to agree to a restriction you request.
• Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, you may not want a family member to know that you are seeing me. On your request, I will send your bills to another address.
• Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI in my mental health and billing records used to make decisions about your for as long as the PHI is maintained in the record. An appointment will be scheduled to review these records in my presence so that any issues can be discussed. Normal hourly and/or copying changes will apply. I may deny your access to PHI under certain circumstances, but in some cases you may have this decision reviewed. On your request, I will discuss with you the details of the request and denial process.
• Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. I may deny your request. Upon your request, I will discuss with you the details of the amendment process.
• Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI. Upon your request, I will discuss with you the details of the accounting process.
• Right to a Paper Copy – You have the right to obtain a paper copy of the notice from me upon request.

Psychiatrist’s Duties:

• I am required by law to maintain the privacy of PHI and to provide you with a notice of my legal duties and privacy practices with respect to PHI.
• I reserve the right to change the privacy policies and practices described in this notice. Unless I notify you of such changes, however, I am required to abide by the terms currently in effect.
• If I revise my policies and procedures, I will notify you at the mailing address you provided.

V. Complaints

If you are concerned that I have violated your privacy rights, or you disagree with a decision I made about access to your records, you may contact me at (770) 212-2249, 5755 North Point Pkwy Suite 67 Alpharetta, GA 30022. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. I can provide you with the appropriate address upon request. You have
specific rights under the Privacy Rule. I will not retaliate against you for exercising your right to file a complaint.

VI. Restrictions

I will limit the uses or disclosures that I will make as follows:

- I will not release the contents of “Psychotherapy Notes” under any circumstance with the following exceptions:

If you file a lawsuit or ethics complaint against me, I may release “Psychotherapy Notes” for use in my defense

- When the following “Uses and Disclosures with Neither Consent nor Authorization” apply:

• Child Abuse
• Adult and Domestic Abuse
• Health Oversight
• Judicial or Administrative Proceedings
• Serious Threat to Health or Safety

HIPAA Signature Attachment

HIPAA is a federal law that provides privacy protections and assures patient rights with regard tothe use and disclosure of your Protected Health Information (PHI) used for the purpose oftreatment, payment, and health care operations. HIPAA requires that I provide you with a complete printed copy of the Georgia HIPAA Notice for use and disclosure of PHI for treatment, payment and health care operations. The Georgia HIPAA Notice explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. We can discuss any questions that you may have about the procedures outlined in the Georgia HIPAA Notice.

I have been provided with the Georgia HIPAA Notice and I understand.

Patient Information and Informed Consent for Telepsychiatry Service

Telepsychiatry is the delivery of psychiatric (or psychotherapeutic) services using interactive audio and visual (video) electronic systems where the provider and the patient are not in the same physical location. The interactive electronic systems incorporate network and software security protocols to protect patient information and safeguard the data exchanged.

Requirements

• An electronic device and a webcam with microphone to video conference using a HIPAA compliant online company specializing in telemedicine.
Potential Benefits

• Telepsychiatry provides convenience and increased accessibility to psychiatric care for individuals who are unable to be treated face to face due to temporary circumstances such as being away at college or an extended stay away from home or having a physical limitation preventing travel to our office.
Potential Risks

As with any medical procedure, there may be potential risks associated with the use of telepsychiatry. These risks include, but may not be limited to:

• Therapy conducted online is technical in nature and problems may occasionally occur with internet connectivity. Difficulties with hardware, software, equipment, and/or services supplied by a 3rd party may result in service interruptions. Any problems with internet availability or connectivity are outside the control of the doctor and the doctor makes no guarantee that such services will be available or work as expected. If something occurs to prevent or disrupt any scheduled appointment due to technical complications and the session cannot be completed via online video conferencing, the doctor will call the patient back at the phone number provided in your chart.

• Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate medical decision making by the psychiatrist or therapist.

• The provider may not be able to provide treatment to the patient using interactive electronic equipment nor provide for or arrange for emergency care that the patient may require, in cases of connection failure.

• Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.

• Although highly unlikely, security protocols can fail, causing a breach of privacy of confidential medical information.

• A lack of access to all the information that might be available in a face to face visit but not in a telepsychiatry session may result in errors in medical judgment.

My Rights

• I understand that the laws that protect the privacy and confidentiality of medical information also apply to telepsychiatry.

• I understand that the technology used by the provider is encrypted to prevent the unauthorized access to my private medical information.

• I have the right to withhold or withdraw my consent to the use of telepsychiatry during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.

• I understand that the provider has the right to withhold or withdraw his or her consent for the use of telepsychiatry during the course of my care at any time.

• I understand that all the rules and regulations which apply to the practice of medicine in the state of Georgia also apply to telepsychiatry.

• I understand that the provider will not record any of our telepsychiatry sessions without written consent.

• I understand that the provider will not allow any other individual to listen to, view or record my telepsychiatry session without my express written permission.

My Responsibilities

• I agree to take full responsibility for the security of any communications or treatment information involved with my own computer and with my own physical location.

• I understand that I am solely responsible for maintaining the strict confidentiality of my access to the telemedicine website and I will not allow another person to use the doctor’s room name. I also understand that I am responsible for using this technology in a secure and private location so that others cannot hear my conversation.

• I understand that the company that the doctor has chosen to conduct the online appointment is an independent company specializing in HIPAA compliant telemedicine. My doctor has no responsibility for that company’s operations or security of my protected health information. In addition, the company might send me emails or communication, such as appointment reminders. I understand that the provider is not responsible for this communication. If I am receiving any unwanted communication from the company, I will call/contact the company directly and address my concerns with them.

• I will not record any telepsychiatry sessions without written consent from the provider. I will inform the provider if any other person can hear or see any part of our session before the session begins.

• I understand that I, not the provider, am responsible for providing and configuring any electronic equipment used on my computer which is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins and I agree to revert to a telephone voice session utilizing the indicated backup telephone number provided below should a video connection not function properly. If I am experiencing any technical difficulties, Dr. Dana Reid, LLC encourages me to call/contact the company chosen for online appointments for technical support.

• I have read and understand that all of the clinic policies of Dr. Dana Reid, LLC apply to all telemedicine as well as all in-person visits.

• I understand that I agree to be seen face to face at least once a year to maintain therapeutic services and a provider/patient relationship.

• I understand that I must establish a medical therapeutic relationship with my proposed telepsychiatry provider in Dr. Dana Reid, LLC office, face to face, prior to commencing telepsychiatry treatment.

• I consent to paying fees that are the same as an in-office visit for the type and length of service provided, by using a credit card number phoned in to Dr. Dana Reid, LLC at the time of service.

• I understand that a telepsychiatry appointment is scheduled the same as an in-office appointment would be, and should I not be available for the appointment or cancel it less than one full business day in advance, there will be a charge for a missed appointment for the time my practitioner has reserved for the scheduled appointment.

Patient Consent to the Use of Telepsychiatry

I have read and understand the information provided in the preceding pages regarding telepsychiatry. I have discussed this information with my provider and all my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telepsychiatry in my medical care and authorize the provider to use telepsychiatry in the course of my diagnosis and treatment.