I acknowledge that the information provided above is accurate and complete to the best of my knowledge and that I consent for myself/child to receive a level of care assessment at BROWNSTONE PSYCHIATRY. I also acknowledge receipt of Privacy Practices received during the registration process prior to my assessment.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

 Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.

 Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with a third party.  For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you.   For example, your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.  For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

 Healthcare Operations: We may use or disclose, as needed, your protected health information to support the business activities of your physicians’ practice.  These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conduction or arranging for other business activities.  For example, we may disclose your protected health information to medical school students that see patients at our office.  In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician.   We may also call you by name in the waiting room when your physician is ready to see you.  We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

 We may use or disclose your protected health information in the following situations without your authorization.  The situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500

 Other Permitted and Required Uses and Disclosures, will be made ONLY WITH YOUR Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physicians’ practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights: Following is a statement of your rights with respect to your protected health information. 

You have the right to inspect and copy your protected health information, under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information: This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.  You may also ask that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices.  Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request.  If physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted.  You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes.  You then have the right to object or withdraw as provided in this notice. 

Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact of your complaint.  We will not retaliate against you for filing a complaint.

 This notice was published and becomes effective on/or before April 14,2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

By signing below, I acknowledge that I have recieved this Notice of Privacy Practices.

Welcome and Thank you for choosing Brownstone Psychiatry. We know that you have a choice in selecting your medical providers, and we are pleased that you have chosen to entrust us with your care. The staff at Brownstone Psychiatry strives to exceed expectations in care and services to make your experience with us positive and stress free.

Psychiatrist Hrs.: Mon.-Thurs. 8:30am-5pm, Fri. 8am-2pm

Therapy Hrs.: Mon.-Thurs. 7:30am to 6:pm, Fri. 7:30 am to 4:00pm

Phone: 281-251-3030        Fax: 281-251-3031

If you need an appointment, prescription refill, please call during regular business hours. Our staff is available 24hrs, 365 days a year by calling our office number. Calls received after business hours, weekends and holidays, will be handled by our answering service. The clinician on call will be contacted for emergency situations only. All other concerns will be addressed during regular business hours.

All suicidal/homicidal ideations/gestures, and self-harm behaviors must be addressed by taking the patient to the nearest hospital for immediate evaluation or by calling 911 for assistance.

 

Brownstone Psychiatry is committed to providing quality care to our clients. To ensure timely service and medical care we encourage patients to schedule their appointments in advance. When calling for an appointment please provide the patient’s name, date of birth, address, telephone number and the chief complaint, as well as your insurance information. We strive to give all patients the time the need; however, emergencies do occur. For this reason, we kindly request your patience and understanding should a delay or rescheduling become necessary on your appointment date.  To ensure quality care, Brownstone Psychiatry does not treat patients they have not seen. We will not call in prescriptions or offer medical advice for patients prior to the initial visit.

If it is necessary to cancel your appointment, please give our office a 24-hour advanced notice. This gives us an opportunity to reallocate time for another patient in need of care. If we are not given prior 24-hour notice you will be charged a fee of $50 for a follow up medication visit and $75 for a therapy session that must be paid at the time of your next visit. There will be a One-Time Waiver for 1st time Cancellation within 24 hours.

At Brownstone, our goal is to give quality time and care to each patient. While we understand there may be some things out of our control, we encourage patients to be ON TIME for appointments. Late arrivals disrupt the flow of the office and may interfere with another  patient’s care. In some cases, a patient may need to reschedule. This will be at the clinician’s discretion.

A “No Show” is someone who misses an appointment without calling or fails to give a proper 24-hour notice. Three (3) “No Shows” within one calendar year may result in a loss of service.  You will also be billed a “No Show” fee in the amount of $50 for a follow up medication visit and $75 for a therapy session, that must be paid before/at the time of your next visit.

 

Please contact the office for refills. DO NOT REQUEST REFILLS VIA PHARMACY, as this causes delay in treatment. Medications will be refilled during office hours Monday-Thursday: 8am-5pm and Friday: 8am-2pm. Please allow 2 business days to complete refill requests. 

We do not have access to your patient record after hours, therefore, no medications will be refilled after hours or on weekends, EXCEPT IN EMERGENCY CASES (ONLY).If your medication is a controlled substance, it must be filed within 21 days of being ordered, or the pharmacy will not fill it. If your prescription is lost, expired or for any other reason must be replaced, it must be picked up at the office. EXPIRED CONTROLLED SUBSTANCE SCRIPTS MUST BE RETURNED TO THE OFFICE. We encourage our patients to review their medications prior to their appointments, provide a medication profile from the pharmacy and request refills at the time of their visit, if needed. Every patient will be given enough medication to last until the next recommended appointment. This should decrease the need for refill requests. Please Note: We do not refill drugs defined as Controlled Substances over the phone.

Brownstone Psychiatry accepts most insurance plans. Please check with your provider to ensure we are in network and any questions you have regarding your plan and coverage. It is a patient’s/guarantor’s responsibility to ensure that clinician being seen is in-network and to update our office of any changes in the insurance coverage. Failure to do so could result in delay or denial to insurance payment. Denied payments become the patient or responsible party’s responsibility. All payments are due at the time of service. We accept cash, and credit cards. No Checks are Accepted.

 

Copies of medical records must be requested in writing, per HIPPA guidelines, to ensure your privacy. A medical release form must be completed prior to the receiving or sending of any medical records and/or materials. Medical records can be faxed or mailed to other clinicians. They cannot be emailed due to confidentiality concerns. There is a $25 fee to copy medical records for patients. The request for records to be sent to another clinician is free. Medical records can contain sensitive information in some cases, the release of medical records directly to a patient, may interfere with doctor-patient rapport. Further discussion may be recommended in those cases. The law allows Medical Offices 30 days to complete requests for records. It is our goal to respond to your request in a timely manner.

The staff at Brownstone Psychiatry will be happy to assist you with various forms and letters required to meet your healthcare needs. Please allow 7-10 days for completion of requested forms/letters.

Due to concerns of liability, please note, FMLA and Short-Term Disability requests are reserved for patients who have an established patient-doctor relationship. Forms will only be completed after at least 3 clinician visits. Also, completion of forms does not guarantee approval for time off or payment via Short Term Disability.

 

Brownstone Psychiatry has the right to terminate services due to failure to comply with policies and procedures. Brownstone Psychiatry also has the right to terminate services due to inappropriate and/or threatening behaviors and/or comments made to clinicians and/or staff.

 

By signing below, I acknowledge that I have received, reviewed, understand, and will comply with the policies and procedures explained in the Brownstone Psychiatry Office Policies and Procedures for Patients Form.