Treatment Policies and Care Agreement
 
Greenlake Psychiatric Services
6800 E. Green Lake Way N Suite #200
Seattle, WA 98115
 
Expectations of Care
As a patient of Greenlake Psychiatric Services you can:
-       Expect to be treated with respect and consideration.
-       Expect us to strive to meet your individual needs
-       Expect your patient information to be kept confidential unless specifically requested or indicated otherwise by law
-       Expect care in a setting that does not practice any discrimination
-       Expect to be an active participant in your care, including receiving information about your condition and options for treatment
-       Expect to have grievances addressed appropriately

Treatment Policies
 
Office Hours
Dr. Sastry’s office hours vary throughout the week.   Currently, her hours are Tuesday and Wednesday 8:30 am to 4:30 pm, and Friday from 8:30am to 12pm.  New patient appointments last for 60 to 90 minutes, follow up appointments are generally 20 to 30 minutes.   Intake forms, consent to treat, and financial policy must be completed and signed prior to your first appointment.  If any forms are missing not signed, the appointment may need to be rescheduled.
 
Appointments:
Dr. Sastry reserves your appointment time for you and will make every effort to start your appointments on time.  If something arises and Dr. Sastry is unable to be at your appointment, she will make every effort to reschedule you as soon as possible.  It is expected that you will make every effort to be ready for your appointment on time with the understanding that if you are late, you will be seen for the time remaining in your appointment, (if more than 10 minutes of appointment time is left) but additional time will not be added.  If there are less than 10 minutes of your appointment time left, you will be asked to reschedule.
There is a $75 cancellation/no show/late cancel fee (see financial policy)
 
Billing
Dr. Sastry is currently a preferred provider with several insurances and is an out of network provider on others. It is your responsibility to check with your insurance prior to appointment.  Physician Billing Partners will, as a courtesy, submit bills on your behalf to the insurance you provide. They can be reached at:  (206) 932-9025

Co-pays, balances and out of network payments are due at the time of your appointment.  We request that you leave a credit card on file for telemedicine visits and outstanding balances. If you are planning on seeking reimbursement from your insurance company as an out of network provider, Dr. Sastry can provide you with a copy of your statement.
 
Communication
Dr. Sastry can be reached via phone at 206-524-5656 during regular office hours Monday through Friday.  Generally, calls will be taken by a staff member and information passed along to Dr. Sastry.  Please be as specific as possible when providing information in order to better manage your care.  Dr. Sastry (or a staff member) will try to address any issues within 24 hours.  Any medication issues may take up to 48 hours.
Dr. Sastry DOES NOT communicate over email in order to better maintain issues of privacy and safety. If you send emails to the general info line, these may be missed or delayed.  NEVER send urgent, emergent, or time based information via email – please call.
 
After hours/emergency
Dr. Sastry will manage her own phone calls after hours through an answering service.  The expectation is that these phone calls are for urgent matters that cannot wait until the next business day.  This is NOT a refill line – these can be left on office line 206 524 5656 as a message and will be taken off the next business day. If there is an emergency, you will agree to go to the emergency room or call a crisis line (206-461-3222), as Dr. Sastry cannot do emergency assessments over the phone.
 
Prescription Policies
Prescriptions will be managed during appointments; refills will be provided during appointments to last until next recommended visit.  It is your responsibility to manage your supply of medication as the processing of urgent requests cannot be guaranteed.   Any controlled substances (stimulants, sleep, short-acting anti-anxiety meds, etc.) need to be monitored closely with frequent visits.  Refills for those medications will not be called in and will require an office visit. 

Dr. Sastry does not prescribe pain medications or medications to acutely manage withdrawal.  Dr. Sastry will also only refill medications that she prescribes.  If you are prescribed medications by Dr. Sastry, you will agree to only get those medications from her and inform her of any other similar medications you are prescribed.  Dr. Sastry can utilize the Washington State Prescription Drug Monitoring Program at her discretion and any suspicious activity or results can alter your treatment.
 
Confidentiality
You can expect that your status as a patient and any accompanying information is confidential unless we explicitly have your written consent.  This applies to picking up prescriptions, providing information to schools, faxing information, sharing information with other providers, etc.   Information, such as diagnoses,

appointments, treatment plans, etc., can be shared with insurance companies that we are billing for you.  You are able to request a copy of your medical records.
 
Social Media and Networking
Dr. Sastry does not engage in social media or networking with patients in order to maintain confidentiality and professional boundaries.
 
Patient Satisfaction and Grievances
Dr. Sastry and her staff work to provide a high-quality, individualized, and effective experience.  If you are in anyway dissatisfied with your care, please address your concerns directly with Dr. Sastry or Dr Naomi Busch (Owner). 

Consent for Care: I consent to the psychiatric examination and treatment of myself.

Treatment Consent for a Minor:

This appointment is for a minor for whom I am the Guardian:

 

consent to the psychiatric examination and treatment of

Advanced Consent to Treat Minors

As a general rule, we require the consent of a parent or legal guardian to provide health care services to a minor child (under the age of 18). We understand that there may be times when a parent or guardian is not able to accompany a child to an appointment. However, we cannot provide care to a child who comes to our clinic alone or accompanied by an adult other than a parent or legal guardian if we cannot reach you or don’t have advanced consent to provide treatment.
Signing the Advanced Consent to Treat Minors form below ensures that we can provide care to your child under these circumstances. This signed form will be kept in your child’s medical record. Consent remains in effect until revoked in writing. Any member of our staff can provide the form to revoke consent.
Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent:
·      If the minor is an emancipated (legally independent) or married to someone at or above age 18.
·      In the event emergency care is required.
·      For birth control and pregnancy-related care at any age.
·      For outpatient drug and alcohol abuse treatment beginning at age 13.
·      For outpatient mental health treatment beginning at age 13.
·      For sexually transmitted diseases, including HIV, beginning at age 14.
 
While we encourage minor patients to involve a parent, guardian or other trusted adult in all aspects of health care, if a minor consents to care as allowed by law, he or she can request confidentiality. That would prohibit us from releasing this information to anyone, including a parent or guardian, without the minor’s express written consent.

If you have questions regarding any of this information, please contact your child’s Primary provider.
 

I, as the parent of legal guardian of the below named minor, authorize and consent to routine and emergency medical treatment for my child when deemed necessary by qualified medical prersonnel at Greenlake Psychiatric Care. This authorization will be in effect until revoke in writing by me.

Greenlake Psychiatric Financial Policy
 
Greenlake Psychiatric participates with a wide variety of insurance plans including Aetna, First Choice, Premera, Regence, Uniform, and others. Dr Sastry is not a participating provider with Cigna, UnitedHealth, Tricare, Medicare nor Medicaid.  Insurance coverage and contracting may change and it is your responsibility to know if we are covered by your plan.
 
As a patient or guarantor, we ask you to know your insurance plan.  Before your visit, call the toll free number on the back of your insurance card.  Make sure you know if Dr Sastry is a contracted in network provider.
Then:
·       Bring your insurance card to every visit.
·       Tell us if your insurance or mailing address has changed.
·       Pay your co-pay or balance at the time of your visit.
 
Cancelation policy:
For all new and established patient appointments, we require at least 48-hour notice if you are unable to keep your appointment.  Missing an appointment and/or canceling with less than 48 hours notice, will result in a cancellation fee.  You will need to pay this fee before any future appointments will be made. 
·       New patients are allowed one missed appointment then they will not be allowed to schedule. 
·       Established patients - three missed appointments within 12 months may result in dismissal from the practice. 
 
Cancellation fee: $75
 
We accept all credit cards, debit and HSA cards, and ACH transfers. We will keep a credit card number on file for your convenience.  Checks returned for insufficient funds will result in an immediate charge of $35.00 against your account. 
 
Billing:
Greenlake Psychiatric will submit bills to insurance companies on your behalf when we are in-network providers.  As a patient, you can expect that we will provide accurate and timely billing.  If we do not contract with your insurance company, we will provide you with a superbill and receipt of payment for you to submit to your insurance company.  There is no guarantee of any reimbursement if we are out of network.  Questions about your insurance bills and account can be answered by Physician Billing Partners at (206) 932-9025. 
 
Insurance Release of Benefits and Release of Information:
·       I authorize Greenlake Psychiatric to request and directly collect, on my behalf, all private insurance coverage benefits due for products and services.
·       I authorize insurance benefits to be paid directly to the provider or clinic.
·       I authorize the providers or insurance company to release any healthcare information necessary to facilitate the processing of claims and audit of payments.
·       I understand that I am financially responsible for any co-payments, deductibles, balances due, and charges for services not covered by my insurance plan

 ·       If insurance benefits are paid directly to me, I will endorse these checks for such payments to Greenlake Psychiatric.
 
All authorizations as above will remain in effect until rescinded in writing.
 
When patient turns 18 years old, they become the guarantors of their account. They will be asked to review their own financial agreements the first time they have a visit after turning 18.
 
I have read and understand this policy.  A copy will be kept in my chart and a copy may be furnished to me at my request.

The following authorization is optional, though it will make it easier to collect co-payments and outstanding balance:
 
Credit Card Authorization:
I authorize Greenlake Psychiatric to charge my credit card (or ACH account) on file for my co-pays and any outstanding balance. These include charges collected for labs, medications, late fees as above.  All charges will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information is stored in my chart or in the office and the card number cannot be accessed once entered. 
·       I can ask and receive a statement of my account which the practice will provide within 5-7 business days
·       Start date of authorization is pursuant to start date of this signed agreement.
·       The authorization is in effect until rescinded in writing.