PatientC Consent Forms

Patient/Provider Contract - Controlled Medications

The DEA classifies certain chemicals according to their acceptable medical use and their potential for abuse and dependency. There are 5 classifications or "schedules":

Schedule 1 substances are defined as drugs with no accepted medical use and high abuse potential. Examples include: Heroin, LSD, Marijuana, Methaqualone, or Peyote
Schedule 2 substances are defined as having high potential for abuse and diversion with potentially severe psychological or physical dependence. Examples include: ADDERALL, VYVANSE, RITALIN, CONCERTA, Combinations of >15mg of Vicodin, Cocaine, Methamphetamine, Methadone, Hydromorphone, Meperidine, Oxycodone, Fentanyl, and Dexedrine
Schedule 3 drugs are defined as having moderate to low dependence potential. Examples include: SUBOXONE, Tylenol with codeine, ketamine, anabolic steroids, and testosterone.
Schedule 4 drugs are defined as having low potential for abuse or dependence. Examples include: XANAX, VALIUM, ATIVAN, KLONOPIN, AMBIEN, TRAMADOL, Soma, Darvon, Darvocet, Talwin.
Schedule 5 drugs are defined as having the lowest risk of dependence or abuse. Examples include: Robitussin AC, Lomotil, Motofen, Lyrica, Parapectolin

Prescription Restrictions According to Department of Justice

Schedule 1 drugs may only be prescribed with limited special license.
Schedule 2 drugs "may not be refilled; a new prescription must be written every time. The individual prescriber must comply fully with all other applicable requirements under the Controlled Substance Act and the Code of Federal Regulations, as well as any additional requirements under state law."
Schedule 3 & 4 drugs may be refilled up to 5 times in a 6-month period.
Schedule 5 medications may be prescribed with no refill restrictions.
In addition, some states and many insurance carriers limit the quantity of controlled substance dispensed to a 30-day supply.

Solutions for Mindfulness Policy on DEA Controlled Medications

In order to comply with updated federal and state laws, as well as to protect the health of our patients, we have developed a policy for dealing with Scheduled Substances. All patients who agree to scheduled prescriptions from this practice also agree to the following:

This clinic REQUIRES monthly visits for Schedule 2 and 3 drugs. In some rare exceptions, subject to provider approval and as noted above an extended script may be given. Failure to keep these appointments may result in discontinuation of controlled medication.
If you are out of medications and need them urgently you may call the office to schedule an appointment at the next available date. Appointments are REQUIRED to fill any scheduled drug. Reminder: Refill of controlled substances is not considered an emergency.
This clinic REQUIRES patients who are taking scheduled substances to refrain from taking other controlled or illegal substances. This clinic will perform random Toxicology screens subject to the provider and relevant laws. Concurrent Marijuana use must be discussed with the provider.
This clinic REQUIRES that all refill requests for Schedule 4 and 5 drugs be sent through the patient portal or via an email or phone call to the office. This clinic also requires a period of 1-2 days to complete refills.
This clinic REQUIRES that the patient NOT engage in abusive or disrespectful behavior toward the provider or staff. Failure to maintain a polite and respectful relationship may result in discontinuation of the controlled medications and possibly discharge from the practice.
The patient CONSENTS to release of information to local emergency department and/or other providers as needed.
The patient CONSENTS to informing the clinic of changes to insurance or pharmacy preference in a reasonable time.
The patient UNDERSTANDS that compliance with state and federal laws also means that past prescriptions will be reviewed by the provider.

I, hereby, acknowledge that I have read and understood the Policies set forth by Solutions for Mindfulness. I recognize that the policies help protect the clinic and myself. Should any of the above policies be broken, discontinuation of scheduled medication and discharge from the practice may result.

Patient Name (Print):

Patient Email:

Patient Signature:

Date:

EMAIL INFORMATION

Email Address:

By providing my email address above, I agree to allow Solutions for Mindfulness to send me my Health Care Information electronically, which may include but is not limited to; appointments and medication information. This information will be protected by a "Pin" number.

Notice of Privacy Practice Acknowledgment

I hereby acknowledge that I have received a copy from Solutions for Mindfulness, PA, of the Notice of Privacy Practice.

Addendum to Privacy Practices

If a psychiatric evaluation for court is required for a patient, any information provided to the health care provider may be released to the court without patient permission.

A court-ordered psychiatric evaluation is also not a treatment relationship between provider and patient.

By signing below I have read and agree with the terms above.

Signature of Patient:

Date:

Patient Consent and Treatment Policy

Thank you for choosing Solutions For Mindfulness for your healthcare needs. We want to maintain an excellent provider and patient relationship with our patients. Informing patients in advance of our office policy allows us to effectively work with patients to achieve our goals successfully in patient treatment.

*Please read the following billing and office policies carefully to understand your responsibility as a patient

Insurance and Payment Policy

We participate with most insurance companies. For plans requiring copays, you are responsible for that copay at the time of service.
It is your responsibility to know the extent of coverage your insurance plan offers. If your insurance requires a referral from your primary care provider, it is your responsibility to obtain the referral prior to the appointment.
Verification of benefits is not a guarantee of payment or coverage. All charges are subject to medical review and approval by your health plan.
Patients are responsible for any out-of-pocket expenses not covered by insurance, including deductibles, copayments, co-insurance, and non-covered services.
For any returned checks, there will be an additional service charge, and we will only accept cash or credit card payment to replace the returned check.

Self-Pay Patients

The patient is required to pay, in full, the office visit fee at the time of service.

Statements with Balances

Statements of due balances are mailed to our patients monthly. The statement shows an itemized listing of your outstanding balance.
Payments are to be paid in full unless notified by our billing department.
If not paid within 30 days, your account will incur a late fee and will be forwarded to collections.
You will be required to pay the collection agency’s fees for collection, court costs, and/or reasonable attorney fees.

Missed Visit/Appointment Cancellation Policy

We make every effort to accommodate your scheduling needs. Please notify our office at least 24 hours in advance if you cannot make an appointment.
Missed appointments, office visits canceled or rescheduled without sufficient notice (1 working day/24 hours) will incur a charge of $65.
If you have missed 2 or more appointments in a 90-day period, you may not be rescheduled, and services may be discontinued.

Electronic Medical Records (EMR)/Electronic Prescribing (e-Prescriptions)

Electronic medical records allow us to store information confidentially to maintain efficient and accurate treatment.
EMRs include electronic medical records used to send patient healthcare information, including appointment reminders and medication information.
Our practice abides by HIPAA regulations at all times.

Controlled Drug Policy

We abide by state regulations for controlled medications.
We conduct random urine toxicology screenings as requested by the provider. If required, there is a $15 fee for collection and screening.
This fee is not covered by insurance.

Treatment & Therapy

As part of a successful treatment, I understand and grant Solutions For Mindfulness permission to provide therapy.
I understand my psychiatric treatment may be contingent on attending regular therapy sessions.
In case of an emergency, I authorize the staff of Solutions For Mindfulness to provide or seek emergency medical treatment.

By signing below, I agree that I have read, understand, and agree to abide by the above policies of Solutions For Mindfulness, PA.