Welcome to my practice.  I look forward to working with you.  Please read these policies carefully and acknowledge your agreement and consent to treatment by downloading the PDF of this document, located at the bottom of this page, signing and returning to me prior to our first meeting.  

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Services Provided:

 

• I am a licensed physician in the state of Washington.  I am a board-certified psychiatrist and provide medication management and psychotherapy to adults.  After our initial visit, we will discuss treatment options and recommendations.  Together, we will decide on the best course of care for you.  Psychiatric treatment is a partnership and requires active participation from both of us.

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• To better involve you in your care, I use an electronic medical record that allows you to create a Patient Portal account, where you will be able to access office documents and provide me with important information about yourself.  You will also be able to securely communicate with me through this portal.  Please make sure that I always have updated contact information for you.

 

Confidentiality:

 

All information is strictly confidential with the following exceptions:

 

• When you give me written permission to release the information to someone.

• When legal and ethical responsibilities require me to disclose information for safety reasons, such as instances of a patient threatening harm to self or others.

• When ordered or subpoenaed by court.

• By law, I must report abuse of children or mentally disabled/vulnerable adults to Child or Adult Protective Services.

• When it is necessary to obtain payment that is due.

• If you are applying for reimbursement from your health insurance, I may be required to provide your health plan some or all of your records.  By signing this form, you consent to release that information to your health insurance plan.

• Please see the Notice of Privacy Practices for further information.

 

Insurance:

 

• I am contracted with Regence and Premera plans only.  I submit insurance claims only to those two carriers or to other Blue Cross/Blue Shield associated with those two companies.  If I submit a claim for you, you may still be asked to pay a copayment at the time of the appointment, a coinsurance payment after the appointment, or a fee for the entire maximum billable amount if you have an unmet deductible.  It is your responsibility to make sure that I am a preferred provider under your plan.  I suggest that prior to your first appointment you call your insurance company and verify that I am in your network.

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• I am an “out of network” provider for all other insurance plans including Medicare and Medicaid.  In such a circumstance, full payment is due at the time of each visit, and I will provide you with a receipt.  You can submit this receipt to your insurance company for reimbursement directly to you at “out of network” rates.  Many plans offer “out of network” benefits, though some do not.  If you are planning to seek reimbursement, I encourage you to contact your insurance carrier to find out about your “out of network” benefit so that you can anticipate your out-of pocket expenses prior to scheduling an appointment.

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• It is your responsibility to report any changes to your insurance plan.

 

Fees and Payment:

 

• The fee for the first new patient visit is $300.  The visit lasts 60 minutes.

• The fees for return visits vary depending on the complexity and type of care provided.  The range is $175-$275.

• Payment is due at each visit.  I accept cash, checks, debit card and credit cards.  NSF checks are subject to a $25 fee.

• I require each patient to have a valid credit card on file to charge for any outstanding balances.  Please see credit card authorization form for further information.

• A fee of $50 is assessed for any medication prior authorization that requires more than 15 minutes of my time.

• If paperwork is required for any reason you should schedule an appointment and have it completed in session.  If you ask me to complete paperwork or write a letter outside of a session a $100 fee will be assessed.

• The fee for chart notes/medical records is $0.25 per page.

 

Cancellations and Missed Appointments:

 

• Your appointment is reserved exclusively for you, so please give at least 24 business hours notice for any appointment which you are unable to keep.  Full fees are charged for missed appointments and cancellations with less than 24 business hours notice.  Please note that insurance does not reimburse any portion of these missed appointment fees.

• Missing appointments interferes with the efficacy and continuity of your care.  A pattern of repeatedly missing appointments is grounds for termination of care.

 

Prescriptions:

 

• I will write prescription refills during our visits.  I will give you enough refills until your next appointment.  Please make sure that you have an appointment scheduled before you run out of refills.  In the rare occurrence that you need a refill between visits, please have your pharmacy fax me directly at (206) 448-7008.  It can take up to 48 business hours to fill a refill request but they are usually done on the same day.

• For most medications, I will send an electronic prescription to your pharmacy.  For controlled substances which require a paper prescription, I will provide you with a written prescription during your appointment.

 

Contact Outside of Appointments:

 

• Due to my lack of office staff, I expect that a message through the patient portal will be the usual mode of communication for non-urgent matters between appointments.  I will make every effort to respond within 24-48 business hours.  You may also call my office number (206) 448-7004 ext. 1 and leave a message.  My response time for a phone call is typically much longer than for a portal message.

• For urgent matters that can’t wait until the next business day you may call my cellular phone at (206) 755-7617.  Please respect that this is for urgent matters only and it may take me several hours to return your phone call.

• For matters that can’t wait for my return call, you can always call the 24 hour Crisis Line at (206) 461-3222.  

• In the event of a psychiatric or medical emergency, please call 911 or go to the nearest emergency department.

• If I am unavailable during vacations, my office message at (206) 448-7004 will have coverage information.

 

Medical Health, Pregnancy, and Medication:

 

• Please alert me to any changes in your medical health or when you start any new medications, including over the counter medications, supplements, or herbal remedies.

• Some psychiatric medications can pose a hazard to a pregnant woman’s baby.  If you are considering becoming pregnant or suspect that you might be pregnant, please discuss this with me as soon as possible so that we can discuss the risks and benefits of continuing your medication during pregnancy.