PRACTICE POLICIES
PRIOR TO VISIT:
PLEASE READ CAREFULLY BOTH MY PRACTICE AND PRIVACY POLICIES.
IF YOU DO NOT HAVE QUESTIONS OR CONCERNS ABOUT THESE POLICIES, PLEASE SIGN THE ACKNOWLEDGEMENTS OF RECEPT AND UNDERSTANDING AT THE END OF THIS SECTION. I YOU DO HAVE QUESTIONS, YOU CAN DEFER SIGNING UNTIL OUR FIRST MEETING.
COMPLETE THE HEALTH QUESTIONAIRRE AND BRING TO OUR FIRST SESSION.
ALTHOUGHT IT IS A BIT LENGTHY, IT PROVIDES IMPORTANT INFORMATION TO ALLOW FOR THE BEST TREATMENT PLANNING AND OUTCOMES.
IIF YOU ARE USING INSURANCE, PLEASE BRING YOUR CARD TO OUR FIRST SESSION.
INSURANCE
I am a network provider for Premera , Regence and First Choice Insurances. As such, I have agreed to a contracted rate with your insurance company and am able to bill them directly.
If you wish to bill insurance other than those listed, I will provide diagnosis and treatment codes for your to submit to your insurer for reimbursement.
Insurance has become quite complicated as of late and often clients have deductibles to meet before receiving services as well as coinsurance and copays associated with their care.
Insurance companies cover only face-to-face services and do not cover telephone calls, reports or cancellation fees.
IT IS VERY IMPORTANT THAT YOU CONTACT YOUR INCURANCE COMPANY BEFORE OUR FIRST SESSION AND THAT YOU ASK THE FOLLOWING QUESTIONS.
PLEASE NOTE THAT COPAYMENTS ARE DUE AT THE TIME OF SERVICE.
INITIAL EVALUATION
The first appointment usually lasts for 60-90 minutes and involves a detailed assessment of the nature of your problems as well as any other factors that may contribute to your current difficulties. This includes information about your physical health as well. By the end of the session, we will have developed treatment goals and clear “next steps” toward reaching these goals. Counseling about medication options, side effects and effectiveness is an important part of this first session
My fee for this initial session is $300.
MEDICATION MANAGEMENT ONLY
Follow up appointment s allow me to assess the effectiveness of your current medication regimen and to address any side effects. It’s important that you attend regularly scheduled follow up appointments to ensure that treatment is as effective and efficient as possible.
FEES
- Initial evaluation $300
- Brief medication follow up (15-25 min) $75
- 30 minute medication follow up $150
- Longer sessions with more complex issues
(40-60 min.) $ 220
PSYCHOTHERAPY /MEDICATION MANAGEMENT
FEES
Psychotherapy alone (50 minutes) $130
Psychotherapy alone (30 minutes) $70
Psychotherapy and medication (45 minutes) $150
CANCELLATIONS
Please give 24 hours notice if you need to cancel a session.
There will be a charge of $60 for giving less than 24 hours cancellation notice.
Failure to show for an appointment will result in a charge for the full fee for that session.
EMERGENCY /URGENT CARE
IF you require emergency assistance at any time, please call 911. If you have an urgent matter please contact the CRISIS CLINIC at (206-461-3222) or go to the nearest hospital emergency room. Feel free to leave a message on my voicemail however I will most likely be unable to speak with you in a timeframe that will be useful in an urgent/emergent situation. I encourage you to contact a support person in your life and let him/her know about your situation in addition to using the resources outlined above.
MEDICATION REFILLS
Refills are best managed during follow up sessions. I will make every effort to make sure that you have enough medication to last until your next appointment. If you do need a refill, please contact your pharmacy directly and allow at least 48 hours for processing.
My fee for emergency refills (needed urgently before 48 hour timeframe) is $30.
In order to continue to receive refills it is important to keep your appointments and follow our agreed upon plan of care.
COMPLETION OF FORMS
Most forms can be completed during an appointment without a charge.
In the event that this needs to be done outside of the appointment time, a fee will be charged. This fee will be based on the length and complexity of the form or document and the time required to complete it. I will discuss an appropriate fee at the time the request is made. We will agree upon an appropriate fee when the request is made.
SERVICES I DO NOT PROVIDE
Treatment for clients under the age of 18
Couples or family therapy
Court ordered/monitored treatment
Evaluations for disability or Social Security Disability
CONFIDENTIALITY/PRIVACY
Issues discussed in our appointment are generally legally protected as both confidential and privileged. There are some limits to the privilege of confidentiality including but not limited to the following;
If there is suspicion of abuse or neglect of a child, elderly or disabled person
If I believe that you are in danger of harming or killing yourself or another person.
If you report that you intend to harm or kill someone, I am required to notify that person and legal authorities.
Please review carefully both the PRACTICE POLICIES AND PRIVACY POLICIES. AND COME PREPARED TO ASK ANY QUESTIONS YOU MIGHT HAVE.
IF YOU DO NOT HAVE QUESTIONS, PLEASE SIGN AND DATE THE ACKNOWLEGEMENTS BELOW.
COMMUNICATION
I communicate with clients exclusively by phone since information exchanged in e-mails cannot be considered private and secure. Please feel free to leave a confidential voicemail and I will respond as soon as I am able. Calls will always be returned within 48 hours and most often within 24 hours.
There is no charge for phone calls unless they are longer than 15 minutes long.
The charge for a phone call lasting from 15-30 minutes is $30 and for45 minutes is $60. Charges for calls longer than 45 minutes are prorated according to length of time.
ACKNOWLEDGEMENT OF RECEIPT OF “PRACTICE POLICIES”
I acknowledge that I have read, understand and received my own copy of PRACTICE POLICIES and have had an opportunity to discuss its contents. I accept the practice policies and consent to assessment and treatment and understand that it is my right to be an active participant in decisions regarding my care.
I agree to be responsible for payment for all costs of providing services on my behalf including uninsured charges. I hereby authorize and direct Ruth Matheson ARNP and designee to disclose protected information to my insurer as necessary to process my claims.
By signing below, I acknowledge receipt of the “Practice Policies”
Date ______
Printed Name______
Client or authorized signature ______
A copy of this form will be placed in your medical record