NOTICE OF PRIVACY
By initialling below, I acknowledge that I have had the opportunity to review the Notice of Privacy Practices. This signed acknowledgement form of my review will be retained in my medical record, in accordance with HIPAA Privacy Act regulations. It is also available on our website greenlakepsychiatric.com.
I also acknowledge that GPC will call to leave reminder phone calls with date and time, name of provider; on occasion reminder post cards may be sent as well.
By initialling below, I understand that GPC is not assuming the role of “primary care provider” rather I am being provided specific care for a procedure, vaccination, or for specialty care. This may include ongoing care for a specific service and may require one or several visits. I will be financially responsible for each separate visit.
NOTICE OF RIGHTS OF MINOR TO SEEK CARE:
Under Washington State law, minors have the right to consent to certain health care without a parent or guardian’s consent. 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. These situations include:
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 mental health, drug and alcohol abuse treatment beginning at age 13. For sexually transmitted diseases, including HIV, beginning at age 14.
CONSENT TO BE TREATED AND ADVANCED CONSENT TO TREAT MINORS:
I give permission and authorize the providers and staff of Greenlake Primary Care to examine and treat me or the minor listed. If treatment is for a minor, I hereby give permission for the patient to receive treatment. In the rare even that I cannot be reached, I authorize GPC to institute any necessary care for the patient, including hospitalization.
This authorization is in effect until rescinded in writing.
With my signature below, I acknowledge and understand that this information will be kept in my medical record according to and the instructions above will be honored until revoked by me in writing. It is my responsibility to notify GPC should I change one or more of the telephone numbers listed above.
Greenlake Psychiatric Care Treatment Policies Expectations of Care - As a patient of Greenlake Psychiatric Care you can:
Dr. Sastry’s office hours vary. Currently, her hours are Tuesday and Wednesday 8:30 am to 4:30 pm, and Friday from 8:30am to 12pm.
Telemedicine is the use of electronic information and communication technologies by a healthcare provider used to deliver services to an individual when he/she is located at a different location or site than I am. If you receive care through telemedicine, it will be done through a two-way video link-up. The healthcare provider will be able to see your image on the screen and hear your voice. You will be able to hear and see the healthcare provider. The laws that protect privacy and the confidentiality of medical information including (HIPPA) also apply to telemedicine. All financial terms that apply to in person visits as written in our financial policy apply to telemedicine.You have the right to withdraw consent to the use of telemedicine in the course of care at any time, without affecting your right to future care or treatment. By signing the consent to care document you are consenting to telemedicine if you schedule your appointment that way.
Intake forms, consent to treat, and financial policy must be completed and signed prior to your first appointment. If any forms are missing or not signed, the appointment may need to be rescheduled.New patient appointments last for 60 to 90 minutes, follow up appointments are typically 20-30 min.Dr. Sastry reserves your appointment time for you and will make every effort to start your appointments on time. 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.There is a $75 late cancellation/no show/late cancel fee (see financial policy)
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. You are responsible for asking your insurance company if Dr. Sastry is in network prior to your visit and for updating Greenlake Psychiatric if there are any changes to your insurance.
Dr. Sastry can be reached by leaving a message with a staff member or on voicemail at (206) 524-5656 during regular office hours Monday through Friday. 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, or 1 business day. 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 choose to send emails to the practice please understand that they may be delayed and urgent messages should not be sent in email.
Dr. Sastry manages her calls after hours through an answering service. This is for URGENT concerns only. If there is an emergency, you will agree to go to the emergency room or call a crisis. Dr. Sastry cannot do emergency assessments over the phone.
Do not page Dr. Sastry after hours for refills- for after hours refills please leave a message on the staff message line and these will be given to Dr. Sastry during office hours.
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.
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 any way dissatisfied with your care, please address your concerns directly with Dr. Sastry or Dr. Tess Moore (Owner).
Greenlake Psychiatric participates with a wide variety of insurance plans including: Premera and Regence. Dr Sastry is not a participating provider with United, 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 an in network contracted provider.
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.
There is a $75 late cancellation/no show/late cancel fee
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.
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.
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 planIf insurance benefits are paid directly to me, I will endorse these checks for such payments to Greenlake Psychiatric.
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. All authorizations as above will remain in effect until rescinded in writing.
Credit Card and/or ACH withdrawl Authorization:I authorize Greenlake Primary Care to charge my credit card or ACH account on file for all charges as well as any co-pays, or balances that are due. These include charges collected for labs, medications, late fees as above, and other incidentals that will be explained to me prior to any payments being rendered. Credit card numbers and ACH will be entered directly by me or staff into the secure payment system HINT or directly into our online credit card terminal through Transaction Express. No card numbers or bank information will be stored in my chart or in the office and the card number or bank account information cannot be accessed once entered.