Jennifer A. Ganem MS, APRN

Londonderry Square50 Nashua Road, Suite 208Londonderry, NH 03053Tel: (603) 432-3399Fax: (603) 432-3396

INFORMATION AND POLICY STATEMENT

Confidentiality:

My Notice of Privacy Practices has been provided to you. Within certain limits, information revealed by you [and if applicable, your child(ren)] in the course of treatment will be kept strictly confidential and will not be released to any other person or agency outside of those indicated below. There are, however, certain situations in which mental health professionals are required by law to reveal information obtained during the course of treatment to other persons or agencies without your permission. These are: (1) when there is reason to suspect that physical or sexual abuse, or physical neglect has occurred to a minor child; (2) when there is reason to suspect that abuse to elderly or incapacitated adults; (3) when serious threat of violence to identified persons or intent to substantially damage property is disclosed; (4) when serious suicidal intentions are disclosed and the client or guardian refuses voluntary treatment to ensure client safety; and (5) when ordered by a court or a state licensing board.

If you request a phone call to remind you of scheduled appointments, your name [and if applicable, your child(ren)’s name(s)] and phone number will be given to a designated person who has signed a confidentiality agreement. This agreement specifies that s/he will not release any of your personal information to any other person.

I use a billing agency (STAT Medical Management) to process bills for my patients and their insurance companies. The agency has signed a confidentiality agreement indicating that billing agents will not disclose any information to any source without written approval by me. I have given the billing agency permission to communicate with your insurance company on my behalf.

At times, another nurse practitioner may cover for me (i.e. when I’m on vacation). S/he would not have access to my records. S/he may however, need to obtain information from you or your pharmacy in order to assist you. Any nurse practitioner covering for me will maintain confidentiality, as required by our licensure.

If you have any questions or concerns regarding your right to confidentiality, please discuss this with me.

Regarding Your Health Insurance Plan:

Health plans provide coverage only for “medically necessary” mental health services. Although this term varies by insurance company, medication monitoring is generally considered medically necessary. Please ensure that this is the case with your health insurance plan.

It is your responsibility to provide me with the correct billing and health insurance information. If during the course of your treatment your insurance plan changes, please inform me of the change at least 2 business days prior to your appointment. This will allow time to verify your new policy coverage. It is your responsibility to obtain a new authorization for service PRIOR to your appointment. If the minimum notice is not provided, or an authorization is not obtained, you will be responsible for paying in full for any visits not covered by insurance.

Release of Information to Insurance Companies or Managed Care Organizations:

If you are billing health insurance or worker’s compensation for your services with me, limited information must be released to your carrier and their managed care company (if applicable). In most cases, this involves a diagnosis and a verbal or written plan for your care. Many insurance policies authorize the insurance company to obtain or view copies of your medical record, and I may disclose your records without additional specific written consent.

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Cancellation and Rescheduling Policy:

Your appointment time is reserved only for you and cannot be filled without sufficient notice. Should you need to cancel or change any appointments, a 24-hour notice is required, although a 48-hour notice is requested. Please note that Monday appointments must be cancelled by the previous Friday by 5pm. You can leave a cancellation call on my voicemail after hours or on weekends. Any missed appointments or those cancelled with less than 24 hours notice, will be billed at $40. The payment of this fee is required before or at your next appointment. Exceptions are made in cases where extraordinary circumstances prevent adequate cancellation notice. Please note that if in a period of two years, you miss or cancel three appointments with less than the required notice, you may be discharged from my care.

Fees and Billing Policy:

Copayments and self-pay fees are due at the time of your (your child’s) appointment. If you are unable to attend an appointment and send your child with another adult or by him/herself, please send the co-payment with your child. I accept cash, personal checks, HSA cards, credit cards and debit cards. You are responsible for any amounts your insurance does not pay. This includes charges applied to deductibles, amounts not covered due to termination of insurance or change of insurance plans and no show or late cancellation fees. In the event that a balance on your account is left unpaid after 90 days, you may be discharged from my care.

Emergency, crisis, or other clinical service related calls to me that are longer than 10 minutes in duration may be billed at $30 per 15 minutes.

Any legal or forensic services delivered or subpoenaed (including letters, reports, telephone calls, testimony and travel) are billed at the rate of $300 per hour.

Medication Refills:

Appointments are made to ensure that you will have adequate medication until your next scheduled appointment. If you change your appointment, please check to make sure you have enough medication until the new appointment. If you do not, you must leave the prescription information (patient’s name, date of birth, name of the medication, dose, and times it is taken) and the pharmacy phone number on my voicemail at least 2 business days prior to running out of medication. Please note that stimulant medications used to treat ADHD, by law, can not be called into a pharmacy at all and you/your child may be without medication until a prescription can arrive by mail.

Prescriptions that need to be mailed or medication refills that need to be phoned into the pharmacy with a notice of less than 2 business days may incur a $30 charge.

Emergencies:

Emergency situations related to medication rarely occur, but in the event that a medication-related emergency does occur, you can be page me at (603) 289-2400. If you want information pertaining to your medication, but do not need an immediate response, leave me a detailed voicemail message and I will return your call as soon as possible.

Emergency situations related to the focus of your therapy occur more frequently, and in those cases, you should contact your therapist. If you can not reach your therapist and need immediate assistance, you can page me.

Please note that if you, or your child, are experiencing a life-threatening emergency, you should call 911 immediately. If you feel suicidal or homicidal, or your child expresses a desire to hurt himself/herself or another person and you feel the threat is serious, please go to your local emergency room. You do not need my permission to go and paging me may result in an unnecessary delay in obtaining treatment.

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Jennifer A. GanemMS, APRN

Londonderry Square50 Nashua Road, Suite 208Londonderry, NH03053Tel: (603) 432-3399Fax: (603) 432-3396

I have read Jennifer A. Ganem’s Policy Statement and consent and/or acknowledge that:

  1. There are legal limits of confidentiality. These were outlined in Ms. Ganem’s Policy Statement and on the Notice of Privacy Practices I received.
  1. It is my responsibility to provide Ms. Ganem with a minimum notice of 2 business days if my health insurance plan is changing. I understand that it is my responsibility to obtain any necessary authorizations for services prior to my appointment. If a notice of 2 business days is not provided, or a new authorization is not obtained, I am responsible for paying in full for any visits not covered by my insurance.
  1. Certain clinical information (i.e., a diagnosis and possibly a plan for my counseling of medication appointments) will be submitted to my insurance and/or their managed care company (if applicable).
  1. I will be charged $40 for appointments missed or not canceled 24 hours in advance or by 5pm on Fridays for Monday appointments. I understand that payment of this fee is required before or at my next appointment, as insurance does not cover these charges. I understand that if in a period of two years, I miss or cancel three appointments with less than the required notice, I may be discharged from Ms. Ganem’s care.
  1. Forensic and legal services, whether requested or subpoenaed, are billed at $300 an hour, are not covered by my health insurance and are my financial responsibility.
  1. Clinical time spent on the phone with Jennifer A. Ganem MS, APRN and the clinical time she spends with others, as is necessary for my care (or my child’s care), may be billed at $30 per 15 minutes.
  1. It is my responsibility to obtain medication refills at the time of my appointment, or give Ms. Ganem a notice of 2 business days to call medication into my pharmacy. I understand that some medications (i.e. stimulant medication for ADHD,etc) can not be called into a pharmacy and I (or my child) may be without medication until a prescription can arrive by mail. I understand that prescriptions that need to be mailed or medication refills that need to be phoned into the pharmacy without a notice of 2 business days, may incur a $30 charge. I understand that payment of this fee is required before or at my next appointment and that my insurance does not cover this charge.
  1. My co-payment is due at the time of my (or my child’s) visit. In the event, that my child attends his/her appointment without me, I understand that I need to send the co-payment with him/her.
  1. Any account balance left unpaid beyond 90 days may result in my being discharged from Ms. Ganem’s care.
  1. I have received The Notice of Privacy Practices summarizing the uses and disclosure of my protected health information, my rights, how I may exercise these rights, and Ms. Ganem’s legal duties regarding my private health information.
  1. If I have an emergency that is not related to my medication and I have a therapist, I understand that I should contact my therapist prior to contacting Ms. Ganem. If I have an emergency related to the medication that is prescribed by Ms. Ganem, or my therapist is not available, Ms. Ganem may be paged at (603) 289-2400.

**PLEASE SIGN IN THE PRESENCE OF MS. GANEM **

Signature: ______Date: ______

Individual/Parent/Legal Guardian

Child’s Signature: ______Date: ______

If age 12 or older

Witness:______Date: ______

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