Hydara's Mental Health Services
Dr. Mustapha Hydara, ARNP Tel:253.347 2665
615 W. Titus Fax: 253.631 -1375
Kent, WA. 98032 Email:
Introduction: My name is Dr. Mustapha Hydara. I am a psychiatric nurse practitioner. I earned a Doctorate degree from University of Washington, Master of Science degree from Seattle University, and a Bachelor of Science degree from the University of Washington. I am board certified to provide mental health treatment to the adult population, specifically from 18 years to end of life. My qualifications include the ability to diagnose and prescribe medications and psychotherapy for conditions such as depression, anxiety, sleep, mood, and memory problems.
Confidentiality: Your medical record, including the information you share with me is strictly confidential and protected by law. There a few exceptions in which I am obligated to disclose information, and this include when there is evidence of abuse and neglect of a minor, or a threat to someone. In the event of information sharing with other individuals or parties, I will need to obtain your written consent to do so.
Appointments: Your appointment time is reserved for you. Without adequate notice
we cannot use the time for another client. Cancellations or rescheduling must be made
24 hours in advance. If you cancel late or miss your appointment you will be
charged a fee of $50.00. Your insurance company will notpay for missed appointments.
Fees for Private payer : Our standard cash fees are listed below.
Initial psychiatric evaluation / diagnostic interview consultation - $250 / session.
Medication management only $150 / 20-30 min, typically though this is not a time based
Service.
Our standard cash fees are listed above. However, these fees may differ if contracted
as in network with your insurance. Your actual share of cost is determined by the
contract we have with your insurance carrier. My billing office, Northwest Clinical Billing Service,can verify your insurance coverage and whether your insurance carrier requires pre-approval for services. You may contact them directly at 360 491 8002 They willverify your out-of-pocket costs; deductibles and cost shares for services listed above.
FEE COLLECTION: The client or legal guardian of the client is primarily responsible
for payments. Fees not covered by insurance are required at the time of service. If
the cost share amount is not known at the time of the appointment, then 50% will
be assumed. My billing office will submit claims for insurance coverage. Accounts with
balances 60 days past due will be assessed a 1.5-% monthly finance charge. Accounts
90 days past due may be sent to a collection agency. Your signature on this form
constitutes informed consent to release your name to a collection agency if it becomes
necessary. In the event your account becomes delinquent and is therefore in default of
payment, the client or legal guardian is also responsible for all reasonable costs
associated with the collection of this debt, including but not limited to, collection service
fees, attorney’s fees and all court costs and additional legal fees associated with the
recovery of this debt. There is a $35 charge for returned checks.
CHANGING INSURANCE: It is your responsibility to notify us about any changes
in your insurance and verify that we are ‘in network’ with any prospective
plan before changing. If you choose to see us “out of network”, your costs or
contributions may be higher. If you become Medicare eligible we need to be notified
immediately.
OTHER CHARGES: You may accrue other charges if other services are
required. These services, if provided outside of an appointment, are typically not
covered by insurance.
Completion of forms, letters or reports - $200 / hr.
Phone calls and e-mail responses requiring more than 5 minutes - $200 / hr.
Copying: If you are changing providers or moving, please give at least two
weeks' notice to obtain a copy of your medical record. In certain cases, there
may be a charge for this service.
Prescription Medication Refills: Note, medications often run out of refills
when you are due to come back for a re-check. If this is the case, please
schedule an appointment. The local pharmacy and I request 48-72hours
notice for routine refills of prescriptions medications. Please have your pharmacist fax
the office for a refill before you run out. Also be aware that some medications
such as stimulant medication by law cannot be refilled without an actual
original prescription.
Phone calls and messages: Please be aware messages will be returned as
soon as possible. Please be sure to leave your name, phone number and the reason you called. I usually respond to my voicemails within 24-48 hours.
Emergencies: If you have an emergency that cannot wait for our next
meeting, please call the crisis clinic at 206 461 3222 or call 911. Do not call me for life threatening emergencies.
Vacation coverage : You will be notified by phone call when I am taking a vacation. During my vacation, you will be advised to make sure you have enough supply of your medicines, and to contact your primary care provider for any health issues.
Termination of service: I reserve the right to terminate service if deemed necessary at anytime. In such event, I shall provide upon your request medication prescription to last for one month, allowing you to find another provider.
Please sign below to acknowledge receipt, understanding, and agreement of my office guidelines mentioned herein.
Client's full name:______
Signature: ______Date: ______