This is the text of the Patient Information and Intake Form page, which you may save for your own future reference:
We would like to take this opportunity to thank you for choosing Augusta Psychological Associates (APA) for your family’s mental health needs. We value your trust in us. It is the mission of our practice to provide you and your family with comprehensive, up to date services that are of the highest quality. As we begin our work together, it is important that you have an understanding of the philosophy and policies of our practice. Please read the following thoroughly and sign the attached “Informed Consent”statement. We encourage you to talk over any questions you may have with your clinician before starting and at any time that they may arise. We very much value the input of our clients and their families and always welcome your comments about how we might better serve you.
Philosophy APA is a child and family-oriented mental health practice made of a multidisciplinary team of licensed, experienced professionals including psychiatrists, psychologists, social workers and professional counselors. We strive to provide psychiatric care and therapy for a variety of mental health issues including anxiety, depression and problems managing stress, anger and behavioral problems. We also work with clients that are experiencing domestic violence, grief and loss, posttraumatic stress disorder, panic disorder, mood disorders and substance abuse or dependence. APA’s child/adolescent therapists work with ADHD, autism spectrum disorder, behavioral and conduct issues, mood disorders, anxiety, transition issues and childhood maltreatment. They strive to work with both the child and the family. APA provides individual counseling and treatment for substance abuse or addiction. This treatment has a focus on harm reduction as well as providing counseling to address the mental health issues surrounding the patient’s alcohol or drug use whether the treatment focus is harm reduction, substance abuse, or substance dependence. APA also strives to supply Psychological and Neuropsychological Testing, including personality and cognitive assessment. We also strive to provide licensed therapists in behavioral analysis and intervention.Patient expectations:We appreciate that you have taken the first step in making a mental health appointment. Therapy is hard work. For it to be successful, changes must come about in the way individuals think, feel, behave and/or interact with one another. Change is difficult and it takes time and effort. The therapeutic process often involves having to acknowledge parts of our lives that are very uncomfortable; this is not easy for any of us. Treatment will require ongoing effort on your and possibly on your family’s part. It will require honesty and open communication with your provider.
Policies and Procedures Your first consultation session will give you the opportunity to determine if you and your clinician are compatible and to determine if a therapeutic treatment relationship can be established. Your initial appointment with your clinician is a consultation visit only and does not imply formation of clinician-patient relationship. It will be up to you and your clinician to determine if further work together, through creation of a clinician-patient relationship, is the best next step.
Appointments: You will see your clinician on an appointment basis. If you wish, we will try to establish a regular time for your appointment if possible. PLEASE NOTIFY US AT LEAST 24 HOURS PRIOR TO YOUR APPOINTMENT if you need to cancel. If you cancel your appointment within 24 hours of the appointment, you will likely be charged up to the full fee unless you are ill, it is weather related or it is deemed an emergency. You will be responsible for these missed appointment fees as they are not billable to your insurance. A total of 3 late cancellations or missed appointments may result in notification to discharge you from the practice. Reminder calls are a courtesy; not receiving one is not a valid reason for missing an appointment. Payment for Service:You agree to pay in full for services not covered by your insurance and for your portion (co pay) of covered services, including any legal or other costs incurred in the collection of your account if it becomes delinquent. We will file your insurance, but your copay is due at the time of service. If you miss two co pays, another appointment will not be scheduled until your copays are current. If you wish to file your own insurance, you agree to pay the full fee at the time of service. You agree to pay a 1.5% interest charge (18%) per year on balances that are 90 days or more past-due. If you have difficulty paying for ongoing services or have a significant outstanding balance, we may develop a budget plan with you, or your clinician may need to assist you in obtaining alternative services. In the event your account is forwarded to collections you will be responsible for any fees incurred. It is your responsibility to be aware of what services your insurance does and does not cover, and if there are any limitations to treatment, such as limits on the frequency of your visits with us.
Ancillary Services: Our practice provides a number of services that can supplement and enhance treatment for children, individuals and families. Most insurance companies will only reimburse for “face-to-face” services. It is important to remember that insurance will generally not cover these (ancillary) services and requesting/utilizing them is done with the understanding that such fees are paid for out of pocket. These additional services include but are not limited to:
Consultation with Schools, and other agencies: Families and children are frequently involved with multiple resources and agencies in the community. While it is important to coordinate treatment as much as possible, this can be a very time consuming endeavor. In order to address this need, clinicians at APA can provide, with sufficient advance notice, written reports as well as telephone consultations with parents, teachers/school staff, other treatment and care providers, and other agencies. It is only at the explicit request of a parent/legal guardian that contact is made with other agencies. Fees are billed as “Forms”, “Telephone Consultation”, “Correspondence” and/or “Records”. This includes any phone calls by parents/patients that require a response by a clinician (e.g. calls for advice on how to handle a situation, etc).
Prescription Services: If your treatment in our practice includes medications that are prescribed by one of our psychiatrists, they will be happy to provide you with any prescriptions needed at the time of your appointment. You can phone-in a request for medication refills outside of your scheduled appointment time. Most of these can be directly phoned into a pharmacy for you by our office. However, due to the clerical and physician time involved in providing this service a Prescription Refill fee will be billed to your account. If you do choose to utilize the prescription service, please have the following information available at the time of your call to us: The patient’s full name, date of birth, and next appointment date, the name of the pharmacy you would like the prescription(s) phoned into and from the most recent bottle of medication, the medication’s name, dosage strength, and directions on the label regarding amount and times of day taken. Note that this service is only available during normal business hours and we ask that you call in at least two business days before you will run out of your medication. In addition, in some cases your physician may require that you be seen before authorizing refills. We do not accept requests from pharmacies for refills, whether they are called in, faxed, or sent electronically.
Telephone Consultation: Your clinician will talk with you as soon as possible if you need to talk between appointments. If you get our voicemail, please leave us a message and your call will be returned as soon as possible. Telephone consultations of more than five minutes may be billed to you on a prorated basis. Insurance does not cover this service. Contact 911 or go to the closest emergency room for any emergency.
Legal Fees: If required, you agree to pay for any legal fees incurred from Court involvement. This might include actions taken to protect your record (Motion to Quash) and/or appearance in court to defend and/or appeal this action on your behalf. There is a minimum charge of three hours that is due prior to the required attendance at court by your clinician. Any additional time beyond the three hours which can include but is not limited to review of records, report writing, consultation with legal representation, and consultation with other professionals directly involved with the case will be charged on an hourly basis.Please note that only the court may ultimately decide whether or not the requested information or records will be disclosed.
Other: If you require any additional services above and beyond normal services (i.e.: correspondence such as FMLA and disability forms, etc.) you may be charged for these services based on the amount of time required for completion.
Confidentiality:It is our policy to maintain the strict confidentiality of all clients and their records according to the law and professional ethics. In general, no information you disclose will be shared with a third party without your written consent. However, there are some exceptions regarding confidentiality which include the following:
In order to facilitate your medical treatment: Per HIPAA regulations your primary care physician or other specialist that you are currently seeing may call us to discuss your treatment, and in that situation we would disclose information about your diagnosis, your medication, and so on.
In order to collect payment for health care services that we provide: to receive payment for our services, we have our billing office send a bill to you or your insurance company. The information on the bill may include information that identifies you, as well as your diagnosis and type of treatment. In other cases, we fill out authorization forms so your insurance company will pay for extra visits, and this includes some information about you, including your diagnosis. We initiate patient billing transaction in-house, but submit many transactions online, through encrypted internet billing gateways.
In order to facilitate routine office operations: We additionally offer electronic submission of prescriptions through an encrypted prescription submission network. The abuse or neglect of a child or dependent adult.
Imminent danger of hurting yourself or someone else.
In order to follow through on a court order or subpoena. It is disclosed that you have a contagious or life threatening disease.
Additional: Please refer to full list of exceptions and protections in your Notice of Privacy Practices.
Unless other arrangements are made, payment for sessions is due at the time of the session(either full fee if you are paying privately, or your co-payment if we are billing your insurance company). Insurance is billed as a service to our patients; however, insurance companies do not guarantee payment and if insurance payments are not received within 90 days of service, responsibility for payment switches to the you, the patient or your guardian or guarantor. Office staff and your clinician are available to discuss payment issues with you. Every patient is responsible for assuring appropriate coverage for services requested, if using insurance. Not every provider accepts every (or any) insurance.
Speak with front office staff about obtaining a fee schedule for counseling and testing services.
Possible Add-on Charges to Primary Medication Management Visits: Individual Psychotherapy, insight oriented, behavior modifying, and/or supportive therapy with the patient and/or family (90833) – $57.00 Individual Psychotherapy, insight oriented, behavior modifying, and/or supportive therapy with the patient and/or family (90836) – $92.00 Individual Psychotherapy, insight oriented, behavior modifying, and/or supportive therapy with the patient and/or family (90838) – $101.20 Interactive Complexity (additional family members, calls to other physicians or pharmacies during or around time of visit; 90785) – $25.00
Other Fees: Telephone Consultation (<10 minutes; 99441) – $10.00 Telephone Consultation (11-20 minutes; 99442) – $20.00 Telephone Consultation (20-30 minutes; 99443) – $40.00 Report Preparation – $25.00 per 15 minutes Prescription Refill (between visits; all prescriptions are otherwise sent-in during appointments) – $15.00 Court Related (Testifying, Preparation) – $350.00 per hour (3 hour minimum)