Welcome to Serenity Behavioral Medicine LLC (SBM), office of Dr. Mona Shah. Please read the following information carefully so you have a clear understanding of our policies concerning communication, fees, insurance, confidentiality, etc. This acknowledges that we have provided you the opportunity to review our Practice Policies and Procedures as is required by federal law. Please take your time to review and fully understand this document.

Professional Services:

At Serenity Behavioral Medicine LLC, we realize how stressful it can be to establish care with a new physician, especially when discussing your mental health concerns. As such, we aim to provide a patient-centered, nonjudgmental environment where you can feel comfortable discussing your concerns. We offer multiple services to our patients. The greatest service you will receive from our office is healthcare with a personalized touch.

As we are a small practice, we have the ability to get to know our patients better than larger clinics. We offer a thorough diagnostic evaluation in a comfortable setting. At the conclusion of your first visit, we will share our thoughts on your diagnosis, answer your questions, and discuss potential evidence-based treatments. We also offer a variety of follow-up visits to suit your needs. Whether you prefer a 15 minute follow-up visit or a more comprehensive 30-45 minute follow-up visit so that we can work to meet your needs.

Services include assessment, diagnosis, and on-going medication management.. We treat a variety of mental health conditions including Major Depressive Disorder, Anxiety Disorders, PTSD, Obsessive Compulsive Disorder, ADHD, and Bipolar Disorder.

For your convenience, we offer telepsychiatry appointments. Through this video conferencing service, you will be able to attend your psychiatric visit from the comfort of your home. Telepsychiatry visits are only available for follow-up visits at the discretion of the physician.

We do not provide forensic services such as custody evaluations, assessments recommended by probation, ability to stand trial, legal matters of medical opinion, etc.

We do not perform disability determinations or fill out paperwork for long-term disability or workers compensation. We do not offer neuropsychological or psychoeducational testing.

We do not fill out paperwork for any organization unless you have been a patient for 6 months or longer or have been seen a minimum of 6 times.

We do not write letters in support of an Emotional Support Animal.

In some situations, Serenity Behavioral Medicine LLC, may not be able to meet your mental health needs and we will give you information where you can obtain care elsewhere. Additionally, if you feel that Serenity Behavioral Medicine LLC and/or your provider is not well matched to your needs, we will be happy to provide you with referrals to other mental health professionals.

You will not become a patient at Serenity Behavioral Medicine LLC until both you and your physician decide together that this treatment relationship is appropriate.

Consent for Treatment/Treatment Issues

All treatment is strictly voluntary and you may choose to stop treatment at any time you wish. If you experience any problem(s) with medication, it is your responsibility to inform your physician of the problem(s).

Office Hours and Appointments:

Business Hours: Office hours are from 8:00 A.M. – 5:00 P.M. Monday through Friday.

Appointments: Initial/consultation appointments for patients are generally 30-45 minutes. Often, the initial appointment provides enough time to complete the evaluation, but there are times where it is necessary for an evaluation to take place over several weeks. Initiation of treatment may need to be delayed until the evaluation is complete.

Please bring all medication bottles and intake paperwork (if not completed electronically) with you to your first appointment. If available, please bring copies of your past medical and mental health records to your appointment, including testing or laboratory work. Please have the contact information for your previous mental health providers and other physicians so that we can obtain collateral information, if needed.

Follow up appointment times are shorter in duration. Both short and long follow up appointments are available.

Appointments are expected to start on time and end on time. Please be aware if your appointment extends beyond the allotted time for any reason, you will be charged for the additional time at the prorated hourly rate.

Appointments provide time with the doctor. An appointment does not guarantee any specific medications, treatments, or letters. Unattended Children: The practice does not allow and is not responsible for unattended children in the waiting area. We apologize for any inconvenience this may cause.

 

No Shows/Late Cancellations/Late Arrivals:

We do not overbook appointments. Your appointment time is reserved just for you. If unable to come to your appointment, please reschedule through the patient portal or leave a message on the office line during business hours to reschedule. If you contact the office within 48 business hours (excluding weekends and holidays) of your appointment you may reschedule with no additional cost, and the appointment will be offered to someone else.

For example, if your appointment is on a Monday, the cancellation must be made by the same hour on the preceding Friday. If an appointment is not canceled or rescheduled more than 48 business hours ahead, the standard no-show/late cancellation fee will be applied to your account. Stating that you did not receive a reminder does not exempt you from a no-show/late cancellation fee.

Should you arrive more than 10 minutes late for any appointment, you will be asked to reschedule so that an appropriate amount of time and attention may be devoted to your care or you may choose to wait and see if the provider has any openings on the same day. You will still be responsible for payment of the no-show/late cancellation fee. This standard no-show/late cancellation fee is not covered by insurance and cannot be submitted for insurance reimbursement.

Failure to show for your first appointment may result in an inability to schedule further appointments. For initial evaluations, SBM may require full prepayment in order to schedule the appointment. This will be charged to the credit card on file. If you miss that appointment and do not give appropriate notice, that fee is nonrefundable. If you wish to book the initial appointment again, another full prepayment may be required to schedule the second appointment. Please ensure that you give us 48 hours’ notice to reschedule your appointment.

Failure to show for your follow up appointments (or violation of this cancellation policy) on two or more occasions may be grounds for discharge from the clinic. Note that the cancellation fee may be waived in special circumstances, determined on an individual basis (ex: medical emergency- patients may be asked to provide documentation for the same).

For our part, we will make every effort to provide you with adequate notice if the physician will be unavailable for a scheduled appointment and will work to reschedule your appointment in a timely fashion.

Inclement Weather Policy:

In some cases of inclement weather (i.e., hurricane), your appointment may need to be canceled or rescheduled. Please call prior to your appointment to confirm our schedule that day.

In some cases, we may call you to request that you come in earlier or later than your scheduled time due to the weather. If your appointment is canceled, every effort will be made to reschedule your appointment. If you need to cancel your appointment due to inclement weather, you may cancel without a fee. However, you must call at least three hours before your appointment to cancel. If you do not show up or call after your appointment time, you will be charged a missed appointment/late cancellation fee regardless of the weather.

 

 

Communication and After-Hours Policy:

Electronic Communication:

The preferred method of communication is through the secure patient portal. You will get the fastest and most complete response if you state your concern by sending a message through the portal. Please note that all communications will be added to your medical records. Please do not send us a message through the portal that is of an urgent or emergent nature. Please call 911 or go to the nearest ER in case of an emergency. Responses to your concerns through the portal will generally be answered within one business day. We do not communicate via text or email. Text/email communications are not protected and cannot be guaranteed as private.

Phone Calls:

Phone hours are Monday to Friday 8:00 A.M. – 5:00 P.M. Brief phone calls of 5 minutes or less are not charged. Longer, more involved calls are charged as outlined in Professional Fees. Please note that all communications will be added to your medical records. Most routine calls are returned within 48 hours during the above stated business hours. This phone service is not available for emergencies. Phone messages and messages through the portal are not checked after hours, on holidays, or on the weekends. Please check our website for the holiday schedule. If you at any time feel that you require care that includes 24 hours per day coverage, SBM will provide information for another practice. Please note that we do not schedule/cancel appointments or refill medications after hours.

Crisis Management:

SBM does not provide crisis management or emergency psychiatry services. After hours calls are routed to a voicemail and are checked the next business day. If you are in crisis, are having suicidal or homicidal thoughts, or have any emergency, please call 911 or go to your nearest emergency room. You may also call 800-273-TALK, or text 741741.

 

 

Hospitalization:

The physicians at SBM do not have admitting privileges. If there is a crisis regarding your safety, you will be directed to the closest hospital emergency room for evaluation and possible admission.

Patient Portal:

Through the patient portal we may send you questionnaires or other information          prior to your appointment. Please complete any forms/questionnaires at least 24 hours prior to being seen. Again, the patient portal is not for urgent/emergency messages.

Controlled Substance Policy:

We are generally inclined to prescribe non-habit forming medications. If a controlled substance is prescribed please be aware that 90 day supplies will generally not be provided.

SBM generally does not:

• Prescribe benzodiazepines to patients who are taking daily opiate pain
• Prescribe benzodiazepines to patients who are taking stimulant
• May not prescribe stimulant medication (Adderall, Ritalin, etc) unless appropriate diagnostic testing has previously been done and available for review.
• Prescribe controlled substances to patients who use marijuana or illicit
• Will not replace lost or stolen prescriptions of controlled substances without a police
• Prescribe stimulant medications to patients with a history of hypertension unless blood pressure is within normal limits and consistently under good control.
• We reserve the right to require random urine drug screens/saliva tests to obtain further refills for any controlled We may also request you bring in your medication for a pill count. If you are prescribed controlled substances and do not comply with a pill count or drug screen request within 48 hours, you may be terminated from the practice.

Please note it is a felony to accept a controlled substance prescription from the same (or similar) class from any other prescriber without both of those prescribers’ consent and notification. This is referred to as “doctor shopping”. If you receive controlled substances from another prescriber and do not notify the clinic, you will be terminated from the practice.

Professional Fees:

The physician at SBM is in-network with Medicare, Medicaid, and Cigna, and considered an “out-of-network” provider for all other insurances. This means that you pay the full amount at the time of service if the physician does not take your insurance. Fees are collected on the same day of the appointment, including copays. If you are not able to pay for your appointment in full prior to the start time, you will need to reschedule. The expectations in this policy also reflect any future insurance companies with which SBM may become in-network.

Upon request, patients who are paying out of pocket for their care are provided with invoices to submit to their insurance company for possible reimbursement. Insurance reimbursement depends on an individual patient’s policy terms. We are not responsible for filing or ensuring insurance reimbursements for insurance plans we do not accept. Your insurance plan is a contract between you and the insurance company and does not directly involve the doctor. Even if your insurance company reimburses you for your treatment, they may limit the amount of treatments for which you may receive reimbursement. Some services may not be reimbursable by insurance such as fees for filling out forms, writing letters, writing reports, etc. Please be aware insurance companies generally require some basic information about your care if you choose to seek reimbursement. Once this information is provided, it will be subject to the privacy policies of the insurance provider. Please check with your insurance company before making an appointment to determine what out-of-network benefits are available to you.

Insurance Claims:

As a courtesy, SBM will file insurance claims for Medicare, Medicaid, and Cigna. Your insurance company, in lieu of reimbursing you directly, will pay the physician or SBM any benefits for services rendered. Your medical insurance carrier may pay less than the actual bill for services, so you may be responsible for payment of some or all of the services rendered. You are responsible for making available complete insurance information for accurate filing of claims. To meet this end, we require updated insurance information at each visit. Reduction or rejection of your claim by your insurance company does not relieve the financial obligation you have incurred. It is your responsibility to know and understand your medical insurance coverage. Not all services are a covered benefit in all contracts. Please call your insurance company to verify your benefits.

SBM will not be able to file claims to your insurance company unless you provide us with accurate and complete information about your

 

insurance plan. Please review your policy carefully and be aware of any limitations on your benefits. Please be aware of your copay and

deductible prior to your appointment.

Referrals and Authorizations:

Some insurance companies require that prior to any visit with a specialist you must obtain an authorization or a referral from your primary care physician. It is your responsibility to know if this is required by your insurance and, if so, to obtain the referral. If this is not done 48 hours before your appointment, you will be asked to either reschedule your appointment or pay the full amount for all services on the day of service. If your insurance company rejects a claim because a valid authorization or referral was not in place, the full cost of the visit will be your responsibility.

Payment for Service

Please note that you are ultimately responsible for all charges incurred for your treatment or the treatment of those for whom you are responsible. If for any reason your insurance company, or other third-party payer (such as a divorced spouse or lawyer), does not promptly reimburse SBM for services rendered, you will be responsible for those charges.

You may pay with cash or credit/debit at the time of service. If you choose to pay with cash, please have the exact amount.

You will be required to leave a confidential credit card on file that may be billed for services provided outside the office, like clinical phone calls. Your credit card is used to secure payment in the case that there is a no-show/late cancellation.

You are responsible for fees from credit card companies, collection agencies or banks due to non-sufficient funds, payment disputes, or non-payment of fees. Please notify us if there is any change in your payment information or if any problem arises in your ability to make payments. Overdue accounts may be referred to collection agencies as a last resort.

Fees are subject to change and reflect the complexity and type of service(s) provided. You will be notified thirty days in advance of any changes in our fees.

Basic Fees:

• Initial/Consultation appointment (30-45 min): $250
• Short follow-up appointment (15 min): $125
• Long follow-up appointment (30-45 min): $250
• Physician Hourly Rate (60 min): $360
• Telepsychiatry short follow-up (15 min): $125
• Telepsychiatry long follow-up (30-45 min): $250
• Telepsychiatry Physician Hourly Rate (60 min): $360
• Phone calls: Phone calls under 5 minutes are not charged, but phone calls above 5 minutes length will be charged at the prorated Physician Hourly Rate stated above
• physician services per 10 minutes**: $60
• Standard no-show/Late Cancellation Fee: $40

**Please contact us if you have questions about which types of services are billed. Some examples include letter preparation, clinical phone calls, etc. Services will be billed at $60 per 10-minute increment. This amount is not covered by insurance and cannot be billed to insurance.

Please note that you will not be billed for phone calls related to scheduling, billing, or other non-clinical questions.

Please note that all services provided after business hours (outside 8:00 A.M. – 5:00 P.M. Monday-Friday) are billed at twice the standard rate.

Forensic Affairs:

If your physician is subpoenaed to appear in a court action involving the care that was delivered to you, you will be charged a fee for court appearances. Please note the fees related to court cases (preparing for depositions, travel time, court time, etc.) are billed at a higher hourly rate than basic services. For more detailed information, please contact us directly.

Medical Record Requests, Letter, and Forms:

We will try to complete all work during our scheduled sessions. It may occasionally be necessary for us to charge on a prorated basis for professional services that require extensive time commitment such as report/letter writing, completing forms, telephone conversations lasting longer than 5 minutes, and consultations with other professionals that you have requested.

Medical records requested for the patient’s own use carry a charge and may be provided in the form of a treatment summary at the discretion of the physician and if you are in agreement. Parts of your record that could potentially be detrimental to your psychological well-being may be withheld. Insurance does not cover these fees. Please allow for at least two weeks for processing of records/letters/forms requests.

 

Record Fee:

To cover the costs incurred in handling, copying, and mailing medical records to the patient or the patient’s designated representative, the maximum fee for each request shall be seventy-five cents (75¢) per page for the first 25 pages, fifty cents (50¢) per page for pages 26 through 100, and twenty-five cents (25¢) for each page in excess of 100 pages, provided that the health care provider may impose a minimum fee of up to ten dollars ($10.00), inclusive of copying costs for sending medical records for the patient or the patient’s designated representative.

Medication Refills/Medication Disclosures:

You will be provided with enough medication until your next recommended follow-up visit. When medications are first prescribed, patients are generally seen more frequently, and then less frequently as stability is achieved. The frequency is determined at the most recent visit with the physician. Medications are refilled only for patients who are active in treatment. The longest interval between visits is typically three months. Even if you are stable on your medication, an evaluation of your progress needs to take place.

If you cancel or reschedule your appointment, it is your responsibility to contact your physician if you need additional medication until your next visit. Medications may not be given if you cancel or no-show regardless of the dangers associated with abrupt discontinuation if the doctor feels a clinical evaluation is necessary prior to a refill. Medications may cause withdrawal symptoms when not taken as prescribed, or if abruptly stopped. It is the responsibility of the patient to make follow-up appointments at the recommended interval.

You must tell every doctor and pharmacist every medication you are taking so you do not harm yourself and do not break the law. This includes over-the-counter medications, vitamins, and supplements.

Typically, SBM does not co-manage psychiatric conditions with other prescribers. Therefore, it is expected that you only receive psychiatric medications through your physician at SBM while you are under his or her care. If you obtain psychiatric medications through another provider, it will be assumed you have transferred your care.

If you require additional medication before your next appointment, please contact the clinic as soon as possible. Please allow up to 3 business days to process refill requests for non-controlled medications and 5 business days for controlled substances. Refills are not processed after business hours, on weekends, or holidays. Please review the holiday schedule posted on the website. A refill in advance of an appointment takes time to coordinate and requires documentation. During your appointment, you will be given enough medication to last until your next appointment. However, if you miss or cancel a scheduled appointment and require a medication refill, you will need to see the physician as soon as possible by scheduling the next available appointment. In the case of non-controlled medications and if a patient has been seen within a 90 day period, the physician may be able to provide a partial refill to make it to the appointment.

Before contacting the clinic, please call the pharmacy directly to ensure that you do not have any additional refills on file, possibly under a different prescription. ***We do not respond to pharmacy-generated automated refill requests.***

If you fail to schedule and/or you have not been seen for 90 days, your file will be formally closed and the physician will no longer be your psychiatrist of record, unless plans have been made to the contrary.

Laboratory Studies/Additional Testing:

At times, laboratory studies may be required. Please be aware that the cost of laboratory work is not included in your visit charge and is your responsibility. Completion of necessary lab work may be required prior to initiating or continuing medication.

In addition, you may be referred for psychological testing if warranted which may incur additional costs.

Confidentiality:

Any confidential information disclosed during treatment, or any other confidential information we obtain while attending to you professionally, shall be held in confidence unless you permit us to disclose such information or where we are required to disclose such information by law. Some examples include, but are not limited to the following:

• child/elder/vulnerable person abuse
• imminent threat of danger to oneself or others
• court order/subpoena
• if a mental illness prevents you from providing for your own basic needs such as food, water, shelter, we will be required to disclose information in order to seek hospitalization.
• if there is a reasonable degree of certainty that you cannot operate a motor vehicle or heavy machinery due to epilepsy, dementia, TBI or any other cognitive dysfunction.

Should you choose to submit a super bill for reimbursement of treatment from your insurance company or if you are using your insurance to pay for treatment, it may be necessary to communicate details of your care with them. In order for your treatment to be covered, we may be required to periodically communicate details of your condition and treatment.

By establishing care, you are agreeing to the disclosure of confidential information to other physicians, providers, or therapists involved in your

 

case, where your physician decides it is clinically appropriate to do so. Similarly, if we refer you to another provider within Serenity Behavioral Medicine for treatment, that provider will have access to your records and may communicate with your previous physician. In addition, covering providers will have access to your clinical information should you require care while your physician is out of the office. Please be aware that the audio or video recording of any session is not permitted secondary to therapeutic and privacy issues. If an unauthorized recording is made, it is grounds for termination of the therapeutic relationship.

Mental Health Records:

Medical records are required by law. SBM currently uses an electronic health record (EHR) to record and store patient information. This EHR system is secure and also abides by the HIPAA laws/regulations. However, as with all electronic systems, there are factors that are sometimes outside of our control. We will always strive to ensure your information is kept confidential and compliant with HIPAA regulations. We reserve the right to change electronic health record systems at any time.

Consumer Etiquette:

Disrespectful/ abusive behavior or harassment towards office staff or physicians will not be tolerated and patients will be immediately terminated from the practice should this occur.

Fraternization:

It is important that your doctor has a professional and therapeutic relationship with you and, therefore, not any other type of social or personal relationship. If you feel there is a strong pre-existing relationship (friend, family, etc.) that may affect your decisions, you should consider seeking care from another psychiatrist. If you feel that you do not have any other practical treatment alternative, this must be discussed and agreed to before engaging in active treatment. Further, there is never room for a romantic relationship between patient and physician.

Discontinuation of Treatment:

The physician may discontinue treatment with a patient usually for one of the following reasons:

• Non-payment of your
• Canceling/missing appointments more than two
• Non-compliance with treatment
• Withdrawal of treatment is necessary due to medical, financial, or legal problems or geographic
• Lack of attendance and/or motivation prevents further progress toward goal
• Inappropriate behavior relative to self, staff or other clients (i.e. threatening and/or intimidating behaviors)
• Modification of medications prescribed by your physician is made by the patient without first consulting the physician or a covering
• Obtaining psychiatric medications from another
• Failure to comply with the provisions of the Policies and Procedures as stated in this
• Successful completion of the treatment program initially agreed upon, implying that the patient has made significant progress toward meeting treatment goals.
• Patient chooses to terminate

If you foresee problems in any of these areas, please let your physician know your concerns. If you decide to discontinue treatment, you can do so at any time in person, by phone, or in writing. In the event that you discontinue treatment without notifying your physician, it will be assumed that your therapeutic relationship with her terminated 90 days after your last visit, unless you have an appointment scheduled for a future date, beyond which SBM carries no further responsibility for your care. You may re-enter treatment with your physician at SBM as long as your treatment ended in good standing and she is accepting new patients. Thank you for reading through this important information. We look forward to working with you.

CHANGES TO THIS NOTICE:

We reserve the right to change this notice. We reserve the right to make the revised notice effective for medical information we already have about you as well as any information we receive in the future This Agreement shall not be amended except by written instrument executed by both parties hereto. Should any provision of this Agreement be declared void or ineffective by virtue of any state or federal statute or regulation, or decision of any court or regulatory authority, such declaration shall not invalidate any of the provisions of this Agreement that otherwise remain in full force and effect.