Practice Policies.

CONSENT FOR SERVICES

The Stratford Clinic PLLC (“The Stratford Clinic”) provides psychiatric evaluation, medication management, and psychotherapy services for adolescents and adults. Services may be provided in person or via telehealth to individuals physically located in Colorado. By signing the acknowledgment associated with this Consent for Services, you agree to the following terms.

SERVICES, APPOINTMENTS, AND SCHEDULING
Initial appointments may be scheduled online through the secure patient portal at https://www.therapyportal.com/p/stratfordclinic/. Follow-up appointments should be scheduled directly with your provider or via the patient portal. If you are currently taking medication prescribed by a provider at The Stratford Clinic, you are expected to follow up with your provider at least once every three (3) months, or more often as clinically indicated. You agree to keep your contact and payment information updated through the patient portal.

EMERGENCY AND CRISIS CARE
The Stratford Clinic does not provide emergency or crisis services and does not operate as an emergency or urgent care facility. Messages and communications (including portal messages, emails, and voicemails) are reviewed during business hours only and are not monitored after hours, on weekends, or on holidays. If you are in crisis, have thoughts of self-harm or harming others, or are otherwise in immediate danger, you must call 911 or go to the nearest emergency room. You may also call or text 988 to reach the National Suicide and Crisis Lifeline.

PAYMENT FOR PROFESSIONAL SERVICES AND INSURANCE STATUS
The Stratford Clinic operates as a private, fee-for-service practice. We do not contract with commercial insurance companies, Medicare, or Medicaid, and we do not accept third-party insurance payments. All services are considered “out-of-network.” Payment of fees for services is due at the time of service, unless other arrangements have been made in advance. Payment is accepted by major credit or debit cards (for example, Visa, MasterCard, American Express). Cash and checks are not accepted. Upon request, and only after payment is received, a detailed statement or superbill can be provided so that you may submit a claim to your insurance company for possible out-of-network reimbursement. Reimbursement from your insurance carrier is not guaranteed, and you remain responsible for all fees charged by The Stratford Clinic regardless of your insurance coverage or any reimbursement decisions made by your insurer.

MEDICAID AND MEDICARE
The Stratford Clinic does not accept Medicaid or Medicare and cannot provide services to Medicaid recipients. By signing this consent, you affirm that you are not currently a Medicaid recipient. You agree to notify The Stratford Clinic in writing if you become eligible for, or enrolled in, Medicaid after beginning treatment. If you become a Medicaid recipient, The Stratford Clinic may need to discontinue services and assist with an appropriate referral.

CREDIT CARD ON FILE, BILLING, AND COLLECTIONS
The practice requires that a valid credit or debit card be kept on file. This card will be used to charge fees for scheduled services, late-cancellation or no-show fees, and any outstanding balances. It is your responsibility to keep card information current and to provide a new card if the existing card expires, is cancelled, or has insufficient funds. If payment is not collected at the time of service for any reason, an electronic invoice may be sent to you and payment is expected within two (2) business days. If payment for services is more than 30 days past due, your account may be referred to a collection agency, an attorney, or small claims court for collection. In that event, necessary identifying and account information may be disclosed to those third parties for the sole purpose of collecting payment. By signing this consent, you authorize The Stratford Clinic PLLC to charge the credit/debit card on file for professional services, late-cancellation or no-show fees, and other charges as outlined in these policies. If you withdraw this authorization, you remain responsible for all fees, and payment will be required by another accepted method at or before the time of service.

CANCELLATIONS, LATE ARRIVALS, AND MISSED APPOINTMENTS
If you are unable to attend a scheduled appointment, you must cancel or reschedule at least 24 hours in advance via the patient portal or by contacting the clinic during business hours. Appointments canceled or rescheduled with less than 24 hours’ notice, or appointments that you miss without notice, may be billed at the full session rate. Arriving more than 15 minutes late may result in a shortened appointment or may be treated as a no-show and billed at the full session rate. Repeated late cancellations, same-day cancellations, or missed appointments may lead to modification or termination of services.

FEES AND PROFESSIONAL SERVICES
Standard appointment fees are listed in the current fee schedule, which is available on The Stratford Clinic website and may be updated periodically. As of the date of this Consent, standard fees are:

Therapy:
$180 – 45-minute individual psychotherapy appointment
$215 – 55-minute family therapy appointment
$215 – 55-minute couples therapy appointment
$75 – 60-minute group therapy appointment (per individual, minimum of three participants)

Parenting and Coaching:
$300 – 50-minute parent coaching appointment

Psychiatry:
$450 – initial psychiatric diagnostic evaluation and medical management
$350 – medication management and psychotherapy appointment
$225 – medication management appointment

Professional services outside of scheduled sessions—such as report or letter preparation, clinical documentation requested by you or third parties, completion of forms or prior authorizations, review of records, consultation or coordination of care with other professionals or family members, and telephone or portal communications that require more than brief, routine responses—may be billed in 5-minute increments. The current rate for such services is $40 per 5 minutes (equivalent to $480 per hour) unless otherwise specified. These services may appear on invoices or superbills with corresponding codes and time billed. These services may or may not be reimbursable by your insurance plan. You are responsible for payment of all such fees. Fees are subject to change at any time. The most current fee schedule and practice policies will be posted on The Stratford Clinic website.

COMMUNICATION, EMAIL, AND PHONE CONTACT
The secure patient portal is the primary method for clinical communication. Portal messages are intended for brief, non-urgent matters (for example, clarifying instructions regarding a current prescription). Messages are typically reviewed and answered within two to three business days. The Stratford Clinic and its providers do not monitor portal messages, email, telephone, or voicemail outside of business hours. Email communication is not considered secure. By choosing to use email, you accept the risks that email may be intercepted, misdirected, or accessed by others (for example, employers on workplace devices). Email content may be saved in your medical record. You should not send confidential, highly sensitive, or urgent information by email. Text messaging is not used for clinical communication. For non-clinical matters (such as scheduling questions), you may call 720-735-7649 or email welcome@stratfordclinic.com during business hours. For emergencies at any time, call 911 or go to the nearest emergency room. Telephone calls lasting more than five (5) minutes may be billed as professional services according to the fee schedule.

MEDICATION MANAGEMENT AND REFILLS
Medication management requires regular follow-up appointments. Refill requests should be submitted at least five (5) business days before you run out of medication. Refills are generally not provided for patients who do not maintain recommended follow-up appointments. Medication refills are not guaranteed on weekends or holidays. Lost or stolen prescriptions, including those for controlled substances, will not be replaced. Repeated last-minute refill requests, failure to attend scheduled appointments, or patterns of non-adherence may result in modification or termination of treatment.

CONTROLLED SUBSTANCE POLICY
Providers at The Stratford Clinic may prescribe Schedule II–V controlled substances when clinically appropriate and in accordance with state and federal law. Methadone and buprenorphine are not prescribed at The Stratford Clinic. The Prescription Drug Monitoring Program (PDMP) is reviewed routinely to monitor for safety and potential misuse. By receiving controlled substances from The Stratford Clinic, you agree to: use one pharmacy whenever possible; take medications exactly as prescribed; safeguard medications against loss or theft; not share or sell medication; and inform your provider of any prescriptions from other prescribers. Lost or stolen controlled substances will not be replaced. Requests for early refills or changes in dose may be denied if they are inconsistent with safe prescribing. Evidence of misuse, diversion, or unsafe use of controlled substances may result in the immediate discontinuation of controlled substance prescribing and potential termination of care. Your provider may require you to sign a separate Controlled Substance Agreement and/or authorize communication with other prescribers as a condition of ongoing prescribing.

TELEHEALTH AND TELEPSYCHIATRY
Telehealth services are available only to patients who are physically located in Colorado at the time of the appointment. At each telehealth visit, you may be asked to confirm your identity and your physical location. Telehealth involves the use of electronic communications and may carry risks, including interruptions, technical failures, or unauthorized access despite reasonable safeguards. Telehealth services may not be as complete as in-person services. Your provider may determine that in-person evaluation or treatment is necessary and may recommend or require in-person visits or referral to local services. No specific outcomes can be guaranteed, and it is possible that your condition may not improve or may worsen despite treatment efforts.

CONFIDENTIALITY AND EXCEPTIONS
Information you share with your provider is confidential and is protected by federal and state law. Your provider will not disclose your information without your permission except as allowed or required by law. Examples of situations in which information may be disclosed without your written authorization include: if there is a serious and imminent risk of harm to you or to others; if there is reasonable suspicion of abuse, neglect, or exploitation of a child, elderly person, or vulnerable adult; if a court orders the release of information; if a government agency is conducting a health oversight or compliance review; or if your provider is required to report professional misconduct to a licensing board. Your provider may communicate with other healthcare professionals involved in your care, or with emergency personnel, when necessary to protect your safety or the safety of others. In all cases, only the minimum necessary information will be disclosed. Additional details about how your protected health information may be used or disclosed are provided in the separate Notice of Privacy Practices.

RELEASES OF INFORMATION AND COORDINATION OF CARE
You may be asked to sign a Release of Information form to allow communication between The Stratford Clinic and other healthcare providers or relevant parties (for example, primary care provider, therapist, school personnel, or specialists). For patients prescribed medications, it may be clinically necessary to obtain medical records (such as a recent history and physical or medication list) from other prescribers. You may revoke a release in writing at any time; however, if you decline or revoke permission to communicate with other essential providers and your provider believes this significantly compromises safety or quality of care, your provider may limit or discontinue treatment.

RECORDS, RETENTION, AND FORMS
Your clinical records are maintained in a secure electronic health record system and are retained for at least seven (7) years after the last date of service, or seven (7) years after the patient reaches age 18 for minors, in accordance with Colorado law. After that time, records may be securely destroyed and may no longer be available. You may request copies of your records in writing. Reasonable administrative and copying fees may apply as allowed by law. Providers at The Stratford Clinic do not complete disability insurance claim forms or life insurance claim forms. If you require such documentation, you may be referred to a provider or evaluator whose practice includes these services.

LEGAL WORK AND COURT-RELATED SERVICES
Any legal work performed by providers at The Stratford Clinic is billed separately from clinical services. Legal work includes, but is not limited to, preparation of letters or reports for court or attorneys, depositions, testimony, expert opinions, and travel or wait time associated with legal proceedings. Legal work is billed at a rate specified by the provider (for example, $2,000 per hour), with a minimum fee and billing in defined increments (such as 15-minute increments) and may require a retainer paid in advance. Details of applicable legal fees and minimums will be provided case-by-case. Insurance companies typically do not reimburse for legal work.

TERMINATION OF TREATMENT AND TRANSFER OF CARE
Your provider or The Stratford Clinic may terminate the treatment relationship when clinically appropriate, if you do not adhere to recommended treatment or safety plans, if you repeatedly miss or cancel appointments without adequate notice, if you fail to pay fees, if you engage in abusive or harassing behavior toward staff, or if other circumstances arise that make continued treatment unworkable or unsafe. When possible, you will be notified in advance and may receive up to 30 days of medication (if clinically appropriate) to allow time to establish care with another provider. You may request a list of other local providers, but The Stratford Clinic cannot guarantee their availability. If you decide to transfer your care elsewhere, you should notify The Stratford Clinic in writing and may request that relevant records be forwarded in accordance with applicable law.

COMPLAINTS
If you have concerns about your treatment, you are encouraged to discuss them directly with your provider. You may also contact the appropriate licensing board or the U.S. Department of Health and Human Services, Office for Civil Rights, if you believe your privacy rights or professional standards have been violated. Information on how to file a complaint is provided in the Notice of Privacy Practices.

ACKNOWLEDGMENT AND CONSENT
By signing the associated acknowledgment form, you confirm that you have read, understood, and agree to the policies described in this Consent for Services; that you understand your financial responsibilities; that you attest you are not a Medicaid recipient; that you authorize The Stratford Clinic PLLC to charge the credit or debit card you have provided in accordance with these policies; and that you consent to receive psychiatric and/or psychotherapy services from a provider at The Stratford Clinic PLLC. You understand that you may withdraw consent in writing, except to the extent that services have already been provided or actions have been taken in reliance on your consent.

NOTICE OF PRIVACY PRACTICES

This Notice of Privacy Practices (“Notice”) describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.

OUR DUTY TO PROTECT YOUR PRIVACY
The Stratford Clinic PLLC (“The Stratford Clinic,” “we,” or “us”) is required by law to maintain the privacy and security of your protected health information (“PHI”), to provide you with this Notice, and to abide by the terms of this Notice currently in effect. PHI is information about you that can identify you and that relates to your past, present, or future physical or mental health or condition, the provision of healthcare to you, or payment for that care.

HOW WE MAY USE AND DISCLOSE YOUR PHI
We may use or disclose your PHI without your written authorization in certain situations as described below. In all cases, we will use or disclose only the minimum necessary information to accomplish the intended purpose.

Uses and Disclosures for Treatment, Payment, and Healthcare Operations
Treatment: We may use and disclose PHI to provide, coordinate, or manage your healthcare and related services. This includes communication with other healthcare providers involved in your care. For example, we may share information with your primary care provider, therapist, or other specialists to help coordinate your treatment.
Payment: We may use and disclose PHI to obtain payment for services provided to you. For example, we may share information with an insurer or other third party responsible for payment (when applicable) or generate statements for services provided.
Healthcare Operations: We may use and disclose PHI for our healthcare operations, such as quality assessment and improvement, training, supervision, administrative functions, auditing, legal services, and business management. For example, we may use your information to evaluate the quality of care you receive or to review staff performance.
Other Uses and Disclosures Permitted or Required by Law Without Your Authorization
Public Health and Safety: We may disclose PHI for public health activities, such as reporting contagious diseases, assisting in product recalls, or reporting adverse events related to medications. We may also disclose PHI to prevent or lessen a serious and imminent threat to the health or safety of you or others.
Abuse, Neglect, or Exploitation: We may disclose PHI to appropriate authorities when we reasonably suspect abuse, neglect, or exploitation of a child, elderly person, or vulnerable adult, as required by law.
Health Oversight Activities: We may disclose PHI to health oversight agencies for activities authorized by law, such as audits, investigations, inspections, licensure, or disciplinary actions.
Judicial and Administrative Proceedings: We may disclose PHI in response to a court order or, in some circumstances, in response to a subpoena, discovery request, or other lawful process, but only as permitted by law.
Law Enforcement: We may disclose PHI to law enforcement officials as permitted or required by law, for example, in response to a court order, warrant, or to locate a missing person, or when PHI is evidence of a crime.
Coroners, Medical Examiners, and Funeral Directors: We may disclose PHI to a coroner, medical examiner, or funeral director as necessary for them to carry out their duties.
Organ and Tissue Donation: We may disclose PHI to organizations involved in organ, eye, or tissue procurement or transplantation, as allowed by law.
Research: We may disclose PHI for research purposes when an institutional review board or privacy board has reviewed and approved the research and established appropriate safeguards, or as otherwise permitted by law.
Specialized Government Functions and National Security: We may disclose PHI for specialized government functions as authorized by law, such as national security or intelligence activities, protective services for the President or other officials, or to help determine your eligibility or compliance with certain government programs.
Workers’ Compensation: We may disclose PHI as needed to comply with workers’ compensation or similar programs that provide benefits for work-related injuries or illnesses.
Inmates and Individuals in Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI to the institution or official when necessary for your health or safety, the health or safety of others, or for the institution’s operations.
Business Associates: We may disclose PHI to business associates who perform certain functions on our behalf (such as billing, administrative services, or information technology support). Business associates are required by contract and law to protect the privacy and security of your PHI and to use or disclose it only as permitted by us and by law.
Uses and Disclosures Involving Family, Friends, or Others Involved in Your Care
We may disclose PHI to a family member, close friend, or other person you identify who is involved in your care or in the payment for your care, but only to the extent PHI is directly relevant to that person’s involvement and only when you do not object. If you are not present or are unable to agree or object (for example, due to incapacity or an emergency), we may, using our professional judgment, determine whether disclosure is in your best interest and disclose only the information that is necessary.
Other Uses and Disclosures Requiring Your Written Authorization
Certain uses and disclosures of PHI require your prior written authorization. These include:
Marketing: We will not use or disclose your PHI for marketing purposes without your written authorization, except for limited face-to-face communications or promotional gifts of nominal value as permitted by law.
Sale of PHI: We will not sell your PHI without your written authorization.
Psychotherapy Notes: To the extent we maintain separate psychotherapy notes as defined by HIPAA, those notes generally will not be used or disclosed without your written authorization, except in limited circumstances permitted by law.
Other Uses and Disclosures: Any other use or disclosure of your PHI that is not described in this Notice will be made only with your written authorization.

If you provide a written authorization for any of the above purposes, you may revoke that authorization at any time by submitting a written request to The Stratford Clinic at the contact information below. Revocation will not affect any uses or disclosures that have already occurred in reliance on your authorization.

YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding your PHI. To exercise these rights, you must submit a written request to The Stratford Clinic.

Right to Inspect and Obtain Copies: You have the right to inspect and request a copy of PHI that we maintain about you, with limited exceptions as permitted by law. We may charge a reasonable, cost-based fee for copies, including the cost of labor, supplies, and postage. In certain situations, we may deny your request to inspect or obtain a copy of your PHI. If your request is denied, you may have the right to request a review of that denial.
Right to Request an Amendment: If you believe that PHI we have about you is incorrect or incomplete, you may request in writing that we amend the information. We may require you to state the reason for your request. We are not required to agree to your request. If we deny your request, we will provide a written explanation and inform you of your right to submit a written statement of disagreement to be included in your record.
Right to an Accounting of Disclosures: You have the right to request a list (an “accounting”) of certain disclosures of your PHI made by us in the six (6) years prior to the date of your request. This accounting will not include disclosures made for treatment, payment, healthcare operations, or certain other exceptions as permitted by law. You may receive one accounting in a twelve (12) month period at no charge; we may charge a reasonable fee for additional requests.
Right to Request Restrictions: You have the right to request restrictions on how we use or disclose your PHI for treatment, payment, or healthcare operations, or to restrict disclosures to family members or others involved in your care. We are not required to agree to all requested restrictions, and if we do agree, we will comply with the restriction unless use or disclosure is required by law or needed for emergency treatment. If you pay for a service out-of-pocket in full, you may request that we not disclose PHI about that service to a health plan, and we will comply with this request unless disclosure is otherwise required by law.
Right to Request Confidential Communications: You have the right to request that we communicate with you in a specific way (for example, at a certain phone number or mailing address) or at a different location to protect your confidentiality. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice: You have the right to receive a paper copy of this Notice at any time, even if you have agreed to receive it electronically. A current copy of this Notice will also be available on our website.
Right to Choose a Personal Representative: If you have given someone medical power of attorney or if someone is your legal guardian or authorized representative, that person may exercise your rights and make decisions about your PHI, as permitted by law and upon verification of their authority.

COMPLAINTS AND CONCERNS
If you believe your privacy rights have been violated, or if you have questions about this Notice, you may contact The Stratford Clinic using the information below. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint or for exercising your privacy rights.

Contact for Questions or Complaints:
The Stratford Clinic PLLC
Attention: Privacy Officer
6200 S Syracuse Way, Suite 260
Greenwood Village, CO 80111
Phone: 720-735-7649
Website: www.stratfordclinic.com

To file a complaint with the Office for Civil Rights, you may write to:
U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, DC 20201, or file a complaint online through the Office for Civil Rights website.

OUR RESPONSIBILITIES AND CHANGES TO THIS NOTICE
We are required by law to maintain the privacy and security of your PHI, to provide you with this Notice of our legal duties and privacy practices, to follow the terms of the Notice currently in effect, and to notify you following a breach of your unsecured PHI as required by law. We reserve the right to change the terms of this Notice at any time. Any revised Notice will apply to all PHI we maintain, including information obtained before the change. When we make a significant change to this Notice, we will post the revised Notice on our website and make it available upon request at our office. The effective date of this Notice is listed below

Effective Date: October 28, 2025 (or as updated on the Stratford Clinic website)