Financial Agreement & Advanced Beneficiary Notice

Carencia Mental Healthcare enjoys offering extended visits, combining services such as psychotherapy and psychopharmacology to improve outcomes as well as offer a more efficient model of care. In order to do this, it is important to understand we need to collect payments in a timely manner for services offered as well as fees that have been applied to your account. The guarantor listed on file will be the party legally and financially responsible for the account. This is usually the patient, but can be a parent, guardian, or another entity such as an employer. In the case of the treatment of a minor, only one parent will be listed as we cannot split responsibility.

We accept most major credit cards, checks, or cash. We ask that a credit card be kept on file and up to date. We will process payment on the card for services rendered or to provide payment for charges to your account for balances due. We will only charge your card for services provided or fees discussed in this agreement.

For all missed appointments or late cancellations, we will charge the card on file generally by the end of the respective day or within 24 hours of the visit, however this is not guaranteed and can be at a later time.

Assignment of Benefits

The assignment of benefits authorizes the practice to file the insurance claim, accept payment from the insurance carrier, and collect patient balances directly from the patient and/or guarantor. The Medicare lifetime beneficiary claim authorization gives the provider permission to file claims on behalf of a patient to Medicare. For those health care providers who accept assignment, I hereby authorize any insurance carrier with whom I have a policy to pay directly to that provider any benefits of any policies of insurance to those health care providers who have rendered services to me and who accept such assignment. Information about me that is necessary to substantiate my insurance claims may be released by the health care provider involved in my care.

Financial Responsibility

I agree to pay all charges that are not paid in full by assigned insurance. If such amounts due to the health care providers are not paid after reasonable notice, that account shall be deemed delinquent and a service charge might be added to the amount due. In the event that I default on payment of my account, I agree to be responsible for collection fees and interest due on amounts in default. In the event of missed or late cancel appointment, there will be a fee. A late cancel is considered less than 24 hours in advance. Please understand it is your responsibility to notify our office and you must receive confirmation of our receipt of your communication.

Medicare Lifetime Beneficiary Claim Authorization

I request that payment of authorized medical benefits be made either to me or on my behalf to Maestro Healthcare, LLC for any services furnished to me by the provider. I authorize any holder of medical information about me to release to the Center for Medicare and Medicaid Services and its agent any information needed to determine benefits or the benefits payable for related services. I understand my signature requests that payment be made and I authorize release of medical information necessary to pay the claim. If other health insurance is indicated on item 9 of the CMS-1500 claim form or elsewhere on the approved claim form or electronically submitted claim, my signature authorizes release of information to the insurer or agency shown. In Medicare assigned cases, the provider or supplier agrees to accept that charge determination of the Medicare carrier as the full charge and the patient is responsible only for the deductible, co-insurance, and non-covered services. Co-insurance and deductible are based upon the charge determination of the Medicare carrier.

Non-Coverage

We have reason to believe your insurance company may not pay for the “Items/Services” listed below rendered byCarencia because of certain coverage problems that will be listed under “Reason.” You can still receive this care, since you or your healthcare provider may have good reason to think you need it, but it is likely you will have to pay. We have estimated about how much you may have to pay under “Estimated Cost” to help you decide whether or not to receive the care listed.

Items/Services	Reason	Estimated Cost
Venipuncture	Not in our contract	$25
Urine Drug Screen Cup*	Not in our contract	$15
Missed/Late Cancel Visit 30 minute	Not in our contract	$75
Missed/Late Cancel Visit 60 minute	Not in our contract	$120
FMLA/STD (per completion)	Not in our contract	$60
Social Security/Formal Disability	Not in our contract	$225
After Hours Visit**	Not in our contract	$30
Prolonged Healthcare Service	Not in our contract	$140
Telephone Consultation	Not in our contract	$20
Vivitrol Care/Case Management	Not in our contract	$15

If we are not in-network with your insurance carrier, you will be responsible for the full-service fee. We will provide you with a receipt you may submit for possible reimbursement at your request, however we do no attempt billing for non-contracted insurance carriers at this time. For your convenience, the services fees are listed below.

* The fee associated with the urine drug screen cup is for the cost of procurement and is not regarding the technical/clinical services of evaluating analyzing the results of the specimen sample.

** After hours visits are considered out of the normal operating hours set forth in our agreement with insurance contracts. The qualifying times and days for this designation are visits after 5:00pm CST and before 8:30am CST. The days this covers are Saturday and Sunday of every week and all nationally recognized holidays. This fee is a voluntary fee for those that prefer to have visits after customary hours for their own convenience or needs and is by no means an obligation to attend visits during these times.

Fee Schedule

Our rates, fees, and financial policies are all subject to change at any time. Please know it is your responsibility to check the website for the most up to date costs and fees schedule.

* After hours call are calls are outside of M-F 9-5 hours and that are not related to a recent visit and this is determined by a 48 hours window after the most recent office visit or 24 hours before the next visit.

Service	Fee
New Patient Evaluation	$225
Follow Up Visit Therapy	$225
Follow Up Visit for Medicine	$125
Missed/Late Cancel Visit	$120 Initial/Therapy | $75 Medication/Follow Up
Venipuncture	$25
Urine Drug Screen Cup	$15
FMLA/STD (per completion)	$60
Secondary Claim Filing (Time/Admin)	$20
After Hours Visit	$30
Phone Consultation /After Hour Calls	$20
Vivitrol Care/Case Management	$15/month
Medical Records Request	$25 for for 20 pages. + $0.25 for each additional page. + $10 processing fee. + any postage costs.

Disclaimer

Our rates, fees, and policies are all subject to change at any time. By signing this agreement, as the patient/guarantor, you understand and agree to abide by our financial agreement which includes authorization to charge the card on file for services rendered or fees accrued. I understand that my information will be saved on file for future transactions on my account.

Appointment Agreement

Since all care happens and is contingent on the appointment, we think it is imperative to communicate clearly about our appointment policies. When you schedule an appointment with Carencia we set aside enough time to provide you with the highest quality care. With growing demand for mental health care and limited access to meet this demand, we have more patients who need care than we have room in our daily schedule. When a patient does not show up for their appointment or cancels too close to their scheduled time, we are unable to fill this appointment time with another patient who needs care. This agreement is our attempt to ensure that both you and our other patients receive the care that you need.

Reminders

We send out reminders both via email and SMS. If you choose to unsubscribe from emails or your portal, please know this effects the delivery of your reminders. Our reminders are a courtesy, it is ultimately your responsibility to know your appointment details.

Telehealth Appointments

Currently, we send access and information about your telehealth appointment to the email we have on file for you. Please note, if you have not received the information, it is most likely because it has been flagged into your spam/junk or we do not have the correct email for you on file. It is wise to check this in advance and let us know so we can make sure you have your access prior to the appointment. Lastly, in the event you are running late or are unable to make your in-person visit, we can accommodate you by changing to an online for most patient visits, however there are exceptions.

Late Cancellations

We consider a late cancellation to be within 24 hours of your appointment. We understand at times there are unexpected events or needs that arise requiring the late cancellation of an appointment. We want to be transparent and clear there are fees associated with a late cancellation and the fees are found in our financial policy. The fee will be charged automatically to the card we have on file. If we do not charge the card, please expect to pay the fee at your next visit. In the event there was a true emergency, please let us know and we can review to credit your account for any charges related to the late cancellation. Lastly, if you have reoccurring appointments scheduled, they will be canceled and further appointments can be discussed with staff.

Late Arrivals

We understand events out of our control happen and if you arrive to your appointment late, we will do all we can to accommodate you. In the event you arrive more than 10 minutes late, we may need to ask you to reschedule as to not impeded other patients care. If you are consistently late to your appointments, we consider this a barrier to our ability to provide adequate care.

Missed Appointment

A missed appointment is simply not showing to your appointment whether online or in person without notice. We want to be transparent and clear there are fees associated with a missed appointment and the fees are found in our financial policy. The fee will be charged automatically to the card we have on file. If we do not charge the card, please expect to pay the fee at your next visit. In the event there was a true emergency, please let us know and we can review to credit your account for any charges related to the missed appointment. Lastly, if you have reoccurring appointments scheduled, they will be canceled and further appointments can be discussed with staff.

Termination Notice

We find that doing our part to lay out expectations is a critical component to a successful relationship and to minimize disruptions in care. If there are a combined total of three missed appointments or late cancellations in a 12-month period, we want to be transparent that our policy is to discontinue our relationship with you. It is imperative there is a commitment to attendance as it is necessary for successful treatment.

Consent To Treatment Agreement

I understand the decision to participate in treatment, including its direction, is voluntary.

I understand Carencia Healthcare, LLC will provide information relevant to my decision making including the purpose of proposed treatment(s), viable alternatives, foreseeable risks and benefits, and the potential for lack of benefit. I understand that consenting to treatment is an evolving process and not a simple one-time “permission.” I understand there will be on-going conversations and decision making that will allow for review of previously discussed information and new information, with respect for my autonomy along the way.

I understand treatment is not guaranteed by a physician and can be provided solely by an accredited and licensed Nurse Practitioner.

I understand that, if prescribed a medication classified as a controlled substance, I will be required to submit a point-of-care (POC) urine drug screen (UDS) prior to treatment initiation and random UDS thereafter supported by treatment practice guidelines and suggestions. I understand that, when prescribed controlled substances, POC tests are used for visit decisions, and the Carencia provider will always send out the specimen to a lab for result confirmation, as is the standard of care, with the possibility of additional fees unrelated to Carencia based on lab fees/insurance.

I understand that controlled stimulant medications, such as Ritalin, Vyvanse, and Adderall products, commonly prescribed for Attention-Deficit Hyperactivity Disorder, are not currently prescribed by Carencia Healthcare providers.

I understand that Carencia Healthcare has an attendance policy that applies to me. There are fees associated with late cancel and missed appointments addressed further in the financial agreement. After three (3) late cancel or no show appointments, Carencia will terminate services and refer out to another community provider.

I hereby give my consent to Carencia Healthcare, LLC, and authorize them to provide my mental health treatment. I understand that Carencia Healthcare, LLC will explain my condition(s), foreseeable risks, and methods of treatment for my condition before treatment is provided. I authorize Carencia Healthcare, LLC, to perform any additional or different treatment that is thought necessary if, in an emergency situation, a condition is discovered that was not known previously.

I have carefully read, and I fully understand this Consent to Treatment form and understand I will have the opportunity to discuss my condition and treatment(s) with the care provider.

Medication Consent Agreement

In addition to our focus on lifestyle, behavioral, and perspective changes, Carencia also uses medication to address the biological aspects of health and wellness. The following information is important to review to be aware of our policies most relevant to this service.

Education

If we prescribe medications, we will review the risks, benefits, and alternatives, which are not always medications, at the time of your visit. We encourage you to ask questions and educate yourself, so you feel confident in the decision you make. In addition to our discussion, we encourage you to use your pharmacist as a resource to evaluate potential drug interactions with other prescriptions you might be taking. You will be provided a handout by the pharmacy and the drug manufacturer that you may review. Lastly, MedLine Plus is an online resource we recommend you use if you have any questions/concerns about your medications.

Refill Request

Refills are best addressed at the time of the visit; however, this is not always possible. You must understand that refill requests are your responsibility. If you are in need of a refill outside of the office visit, the requests need to be submitted to us via email or your OnPatient patient portal. We will not respond to a pharmacy’s request for refills due to many irrelevant or inappropriate requests.

If you were unable to attend your most recent visit or had a late cancellation, we will call in a one-time, 30-day supply of that medication with no refills at your request. You will need to follow up with us for an appointment for any further refills.

We will not provide any refills for controlled substances outside of the appointment

Controlled Substances Monitoring/Adherence

If you are prescribed a controlled substance, drug testing is the standard of practice and mandatory. Drug testing is performed at random, routinely, or due to suspicion. We use point-of-care (POC) urine drug screenings for visit decisions and always send off the specimen for confirmation as the standard of practice. There may be additional fees that you, the patient, may be responsible for unrelated to Carencia and are based on lab fees/insurance coverage

Prior Authorization Requests

If the medication we prescribe results in the insurance company/pharmacy stating you need a “prior authorization” to be completed, please inform your insurance pharmacy that we are more than happy to complete all prior authorization requests through the online service CoverMyMeds.

Communication Agreement

Carencia utilizes email communication with our patients to improve the experience, convenience, and efficiency of your care. Email communication with Carencia is not to be used for emergency or urgent medical concerns. If you are experiencing a medical emergency contact 911 or visit your nearest emergency department.

Uses of Email Communication

Email communication will not be used to communicate medical or nursing treatment. If more than simple clarification of established treatment plan is requested, a consultation or office visit will be required. Email communication with Carencia is restricted to the following uses

• Scheduling appointments (including rebooking and cancellation)
• Providing directions (to practice location and other facilities)
• Providing practice policies & protocols
  (e.g. privacy policy, referrals, etc.)
• Providing general educational and health promotion electronic
  documents, resources, and links
• Clinic newsletters and alerts/updates
• Medication Refill Requests

Risks of Using Electronic Communication

Carencia cannot guarantee the security and confidentiality of electronic communications. Please consider the following risks of using email communication.

• Despite reasonable efforts to protect the privacy and security of
  electronic communication, it is not possible to completely secure the
  information
• Employers & online services may have a legal right to inspect & keep
  electronic communications that pass through their system
• Electronic communications can introduce malware into a computer
  system and potentially damage or disrupt the computer, networks, and
  security settings
• Electronic communications can be forwarded, intercepted, circulated,
  stored, or even changed without the knowledge or permission of the
  physician or the patient.
• Even after the sender and recipient have deleted copies of electronic
  communications, back-up copies may exist on a computer system
• Electronic communications may be disclosed in accordance with a
  duty to report or a court order
• Electronic communication can be misdirected, resulting in increased
  risk of being received by unintended and unknown recipients
• Electronic communication can be easier to falsify than handwritten or
  signed hard copies. It is not feasible to verify the true identity of the
  sender, or to ensure that only the recipient can read the message once
  it has been sent

Phone Communication Practices

Carencia is not an emergency care provider, including for
mental health reasons. In the event of an emergent situation
call 911.

• Phones are only answered during clinic office hours
• Please provide your full name and reason for call on voicemails left
• While we strive to return voicemails on the same day, we cannot
  guarantee this turnaround time
• Carencia will leave limited information on your voicemail

Instructions for Email Communication

• Reasonably limit or avoid using an employer’s or other third party’s computer
• Inform Carencia of any changes to your email address
• Include an appropriate and descriptive message subject line
• Include your full name and date of birth in the body of the message
• It is recommended not to include any attachments unless requested
  by your health care provider

Email Communication Practices

• Emails will only be checked during clinic office hours
• Emails will be triaged and answered according to internal
  clinic prioritization
• While we will strive to return all email queries within 24 hours,
  we cannot guarantee this turnaround time
• It is the responsibility of the patient to follow up on all email
  communications
• Any forms submitted through the website will be directed to
  hello@carencia.com, and may be reviewed and responded to by any
  of the clinic’s administrative staff
• Communication is only granted with the email address we have on file

Other Communication Practices

In addition to telephone and electronic email communication,
there are several other options to address.

• Carencia do not communicate by way of text messages
• Carencia does not respond to instant messaging services
• Carencia will use messaging application or services that is offered by the current
• Electronic Healthcare Recording service
• When using communication through the patient portal, the same response times listed above are still followed and it is not to be used for emergencies

Notice of Privacy Practices Agreement

This notice describes how medical information about you may be
used and disclosed and how you can get access to this information.

Please review it carefully.

Overview

Your Rights

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses

• Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

Your Rights - When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you
  can ask us not to share that information for the purpose of payment
  or our operations with your health insurer. We will say “yes” unless a
  law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your
  health information for six years prior to the date you ask, who we
  shared it with, and why.
• We will include all the disclosures except for those about treatment,
  payment, and health care operations, and certain other disclosures
  (such as any you asked us to make). We’ll provide one accounting a
  year for free but will charge a reasonable, cost-based fee if you ask
  for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you
  have agreed to receive the notice electronically. We will provide you
  with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone
  is your legal guardian, that person can exercise your rights and make
  choices about your health information.
• We will make sure the person has this authority and can act for you
  before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by
  contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and
  Human Services Office for Civil Rights by sending a letter to 200
  Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-
  696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint

Your Choices - For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to
tell us to:

• Share information with your family, close friends, or others involved
  in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes
• In the case of fundraising:
  • We may contact you for fundraising efforts, but you can tell us not to contact you again

Our Uses & Disclosures - How do we typically use or share your health information? We typically use or share your health information in the following ways.

Treat you

• We can use your health information and share it with other
  professionals who are treating you.
• Example: A doctor treating you for an injury asks another doctor
  about your overall health condition.

Run our organization

• We can use and share your health information to run our practice,
  improve your care, and contact you when necessary.
• Example: We use health information about you to manage your
  treatment and services.

Bill for your services

• We can use and share your health information to bill and get payment
  from health plans or other entities.
• Example: We give information about you to your health insurance plan
  so it will pay for your services.

How else can we use or share your health information?

• We are allowed or required to share your information in other ways
  – usually in ways that contribute to the public good, such as public
  health and research. We have to meet many conditions in the law
  before we can share your information for these purposes
• For more information see: www.hhs.gov/ocr/privacy/hipaa/
  understanding/consumers/index.html.

Help with public health and safety issues

• We can share health information about you for certain situations:
  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

Do research

• We can use or share your information for health research

Comply with the law

• We will share information about you if state or federal laws require
  it, including with the Department of Health and Human Services if it
  wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

• We can share health information about you with organ procurement
  organizations.

Work with a medical examiner or funeral director

• We can share health information with a coroner, medical examiner, or
  funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other
government requests

• We can use or share health information about you:
  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

• We can share health information about you in response to a court or
  administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your
  protected health information.
• We will let you know promptly if a breach occurs that may have
  compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this
  notice and give you a copy of it.
• We will not use or share your information other than as described
  here unless you tell us we can in writing. If you tell us we can, you
  may change your mind at any time. Let us know in writing if you
  change your mind.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

Other Instructions for Notice

The Effective Date of this Notice is September 14, 2017.

Our Privacy Official is Keirschen Maize and can be reached at 682-478-5333 or by email at keirschen.maize@maestrohealthcares.com.

At time Carencia is not part of an OHCA (organized health care arrangement) where an agreement to provide a joint notice and share your information occurs.

By signing this notice, I am confirming I have reviewed the information provided in its entirety. I understand that I may ask further questions and seek education from Carencia regarding Privacy Practices. I have been given a copy of this or allowed the opportunity to download.

Organized Healthcare Arrangement Agreement

Carencia Community Collaboration
The Carencia Community Collaboration is a partnership of independent entities to improve the flow of referral, access, and outcomes of behavioral healthcare between agencies.

The Health Insurance Portability and Accountability Act (“HIPAA”) defines an Organized Health Care Arrangement (“OHCA”) to include, among other arrangements, an organized system of health care in which more than one covered entity participates and in which the participating covered entities hold themselves out to the public as participating in a joint arrangement and participate in certain joint activities as specified in the Privacy Regulations.

The covered entities included in the list below, each independent of the other, have agreed to collaborate voluntarily to give coordinated high-quality care to their patients.

As part of the Carencia Community Collaboration, the covered entities plan to participate in certain joint activities, including quality assessment and improvement activities, where the sharing of protected health information (“PHI”) on patients in the designated population may be necessary to achieve the goals of the Carencia Community Collaboration. Additionally, and when appropriate, PHI will be shared to improve the quality, coordination, and outcomes of treatment and healthcare operations.

For the purposes of the Privacy Regulations, the covered entities qualify as an OHCA and wish to declare themselves as such for the purposes of the Carencia Community Collaboration and to enable the sharing of PHI for joint activities of the Carencia Community Collaboration. Additionally, unless the participants choose to provide individual notice, this serves as a joint notice of our public declaration.