Practice Policies.

THE STRATFORD CLINIC PLLC

APPOINTMENTS:

· Initial appointments may be scheduled online at https://www.therapyportal.com/p/stratfordclinic/

· Subsequent appointments should be made in-person with your provider(s) or via your Patient Portal which may be accessed at https://www.therapyportal.com/p/stratfordclinic/

· By signing this document, you elect to receive an email and/or text reminders confirming your appointment as well as periodic communications regarding practice updates and changes. You may opt-out of these communications on your Patient Portal website.

· If you are currently taking medication prescribed by a prescriber at The Stratford Clinic, it is expected that you follow-up with your provider at least once every three (3) months for ongoing medication management, or sooner as determined by your provider and your clinical situation.

PAYMENT FOR PROFESSIONAL SERVICES:

· Fee for services are expected at time of appointment, unless other arrangements have been made in advance.

· Phone consults will be charged at the hourly rate.

· Accepted methods of payment include major credit cards (i.e. MasterCard, Visa or American Express). We do not accept checks or cash for payment.

· The Stratford Clinic and its providers do not currently contract with any insurance carriers. Visits with providers at The Stratford Clinic are considered “out of network” and reimbursement is based on your insurance company’s policy. Please check with your insurance company as to whether or not you would qualify for out-of-network benefits.

· If needed, a detailed invoice, or Superbill, can be provided for out-of-network billing purposes if permitted by your insurance provider. Only after payment is received may we generate a receipt that can be emailed to you which will include the information needed for you to bill your insurance company.

· This practice does not accept third-party insurance payments including Medicaid and Medicare; due to Medicaid policies, we are unable to render services to Medicaid recipients. By signing this form, you as the patient or responsible party for the patient (i.e. parent or legal guardian) acknowledges that the patient being treated at The Stratford Clinic is not a Medicaid recipient. Furthermore, you agree to notify in writing both The Stratford Clinic PLLC and your treatment provider if you, after receiving care from The Stratford Clinic PLLC or its providers, subsequently become a Medicaid recipient.

· If payment for services exceeds 30 days from the time of service your account will be turned over to a collection agency, an attorney, or small claims court and any necessary identifying information may be disclosed for collection of payment.

LATE SHOWS, NO-SHOWS AND CANCELLATIONS:

· If you are unable to make a scheduled appointment, you can reschedule via the Patient Portal or the scheduling feature on the website. Notification must be given at least 24 hours in advance.

· If you do not show for an appointment and have not provided 24-hour advance notice, you will be charged in full for the appointment.

· Being more than 15 minutes late to your appointment will count as a no-show. You will be charged in full for the scheduled appointment.

· In case inclement weather affects your ability to make your appointment, contact your Stratford Clinic provider via the patient portal.

Your signature indicates that you understand that payment is due at the time of service. If, for any reason, you do not pay at the time of the appointment, you understand that you will receive an electronic invoice for the applicable fee. You understand that it is expected that the payment will be completed within two (2) business days. You understand that this practice does not accept third-party insurance payments including Medicaid and Medicare; due to Medicaid policies, we are unable to render services to Medicaid recipients. By signing you agree that you are not a Medicaid recipient. You understand that my provider or providers at The Stratford Clinic PLLC are responsible for providing mental healthcare services. By signing this form, you agree that you have carefully reviewed all information in this document. If there is a late cancellation or no-show fee, you understand that your card that you have provided to us will be charged, and if no card is on file you will be emailed an invoice for the fee. If the fee is not paid prior to the next appointment, that no-show or late payment fee will be added to the next appointment fee. You, the undersigned, agree that regardless of any insurance coverage, you are financially responsible for all charges generated for this patient. You understand that unpaid balances over 30 days past due may be referred to a collection agency. By signing below you agree to these terms. You authorize The Stratford Clinic, P-LLC, to bill your provided credit/debit card for professional services as outlined in the Policies. You will notify The Stratford Clinic, P-LLC, in writing if you no longer want your credit/debit card billed, but must provide an updated card for services at the time of your appointment. Additionally, you authorize a provider from The Stratford Clinic, P-LLC (herein may be referred to as the “Stratford Clinic” or “the practice”) to charge your credit card when the patient does not give advance notice for a late-cancellation or no-show, as per the Practice Policies. You understand that if you do not want my credit card billed for this purpose, you are still responsible for these fees and will be billed accordingly.

FEE SCHEDULE:

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)

Psychiatry:

$450 – 90-minute initial psychiatric diagnostic evaluation

$350 – 45-minute medication management & psychotherapy appointment

$180 – 25-minute medication management appointment

$60 – There will be a routine charge for phone calls longer than 10 minutes, billed at $60 per each additional 10 minutes.

$60 – Medication refills requested less than 3 business days in advance, or after-hours refill requests (accommodated only if possible)

Varies – There is a charge of $180 dollars per 25 minutes for disability, ESA, or school letters/IEPs

Varies – There is a charge of $180 dollars per 25 minutes for any prior authorizations

Other Services:

$300– 50-minute Parent Coaching appointment

The fees above are subject to change and can be changed at any time without notice. Please see The Stratford Clinic website for up-to-date fees and practice policies.

CREDIT CARD INFORMATION FOR BILLING AND PAYMENT PURPOSES:

The practice requires that you keep a valid credit or debit card on file with The Stratford Clinic. This card will be charged for the amount due at the time of service and for any fees you may accrue. It is your responsibility to keep this information up to date, including providing new information if the card information changes or the account has insufficient funds to cover these charges. In the event that the individual paying for clinical services (patient, parent, spouse, etc.) would like to change the card initially provided, it is the responsibility of said individual or their personally authorized representative to communicate this to The Stratford Clinic, as otherwise the card on file will be billed per the practice policies.

CONSENT FOR TREATMENT:

The undersigned patient or responsible party (i.e., parent or legal guardian) consents to, and authorizes services, by a provider of The Stratford Clinic PLLC (i.e., The Provider). These services may include psychotherapy, medication therapy, laboratory tests, diagnostic procedures and other appropriate therapies as deemed by the provider.

The undersigned understands that he/she has the right to:

1. Be informed of and participate in the selection of treatment modalities.

2. Receive a copy of this consent.

3. Withdraw this consent at any time. To withdraw consent The Stratford Clinic must be notified in writing.

CONFIDENTIALITY:

Your Provider will not disclose your personal information without your permission unless required by law. If your Provider must disclose your personal information without your permission, your Provider will only disclose the minimum necessary to satisfy the obligation. However, there are a few exceptions.
Your Provider may speak to other healthcare providers involved in your care.
• Your Provider may speak to emergency personnel.
• If you report that another healthcare provider is engaging in inappropriate behavior, your Provider may be required to report this information to the appropriate licensing board. Your Provider will discuss making this report with you first, and will only share the minimum information needed while making a report. If your Provider must share your personal information without getting your permission first, they will only share the minimum information needed. There are a few times that your Provider may not keep your personal information confidential.
• If your Provider believes there is a specific, credible threat of harm to someone else, they may be required by law or may make their own decision about whether to warn the other person and notify law enforcement. The term specific, credible threat is defined by state law. Your Provider can explain more if you have questions.
• If your Provider has reason to believe a minor or elderly individual is a victim of abuse or neglect, they are required by law to contact the appropriate authorities.
• If your Provider believes that you are at imminent risk of harming yourself, they may contact law enforcement or other crisis services. However, before contacting emergency or crisis services, your Provider will work with you to discuss other options to keep you safe.

SOCIAL MEDIA:

• In accordance with American Psychiatric and American Psychological Associations Policies, providers at The Stratford Clinic may elect to not accept friend or contact requests on any social media (e.g. Facebook ©, Instagram ©, etc.).

• Your provider may publish content on various social media websites or blogs. There is no expectation that you will follow, comment on, or otherwise engage with any content. If you do choose to follow your Provider on any platform, there is no expectation that they follow you back.
• If you see your Provider on any form of review website, it is not a solicitation for a review. Many such sites scrape business listings and may automatically include your Provider. If you choose to leave a review of your Provider on any website, they are not obligated to respond. Ber aware of the potential impact on your confidentiality prior to leaving a review. It is often impossible to remove reviews later, and some sites aggregate reviews from several platforms leading to your review appearing other places without your knowledge.

EMOTIONAL SUPPORT/SERVICE ANIMALS:

• Only officially designated emotional support and/or service animals are allowed inside the building.

• Please provide written documentation in advance in these circumstances.

ELECTRONIC MAIL (EMAIL) POLICY:

• We request that all electronic communications should be sent via the Stratford Clinic Patient Portal (“Patient Portal”). We are under no obligation to respond to electronic communications sent in any manner besides through the patient portal once you have become an established patient and also created your patient portal. We assume no liability for failure to respond to any method of electronic communication outside of the use of the Patient Portal.

• By agreeing to communicate via email or the internet, you are assuming a certain degree of risk of breach of privacy. The Stratford Clinic cannot ensure the confidentiality of our electronic communications against purposeful or accidental network interception.

• Due to this inherent vulnerability, we would caution you against emailing anything of a very private nature. Additionally, your provider will save email correspondence with you and these communications should be considered part of the medical record; therefore, you should consider that our electronic communications may not be confidential and will be included in your medical chart.

• To protect your privacy, be prudent in how you store treatment-related emails. Make sure they are protected from unauthorized access by using and guarding your passwords. Consider deleting any emails that you do not want others to see, followed by emptying your trash or recycle bins. Be aware that emails sent from a workplace computer are the property of the employer.

• Never send electronic communications to The Stratford Clinic that are urgent or emergent in nature.

TELEHEALTH & TELEPSYCH POLICY:

In order to receive telepsychiatry services from The Stratford Clinic PLLC, you must be a Colorado State Resident.

Your signature below indicates that you understand that there are risks and consequences from telehealth (also referred to as telepsych) care, including, but not limited to, the possibility, despite reasonable efforts on the part of your provider, that: the transmission of your medical information could be disrupted or distorted by technical failures; the transmission of your medical information could be interrupted by unauthorized persons; and/or the electronic storage of your medical information could be accessed by unauthorized persons.

In addition, you understand that telehealth-based services and care may not be as complete as face-to- face services. You also understand that if your provider believes that you would be better served by another form of behavioral health services (e.g., face-to- face services), you may be referred to a provider who can provide such services in your area. Finally, you understand that there are potential risks and benefits associated with any form of psychiatry and other behavioral health services, and that despite your efforts and the efforts of your provider, your condition may not be improve, and in some cases may even get worse.

COMMUNICATION POLICY:

• The Stratford Clinic and its providers patient portal messaging, emails, telephones, voicemails, are not monitored outside off-business hours.

• Please be advised that messages patient portal and telephone communication should only be used for brief, non-urgent communication (for example, a question concerning current medication).

• For more extensive phone calls (10 minutes or more), please schedule a phone appointment with your Stratford Clinic provider. There will be a routine charge for these phone calls based on the time spent per call; please refer to the fee schedule for additional information.

• Please note that most insurance companies will not reimburse phone consultation fees.

• The Stratford Clinic has a no-texting policy and prefers clients to contact their provider(s) at The Stratford Clinic via their patient portal, and for non-clinical matters you may also communicate through the patient portal or alternatively call 720-735-7649 or email at welcome@stratfordclinic.com during business hours. In the case of an emergency at any time of day or night clients should call 911 or go to the nearest emergency room.

MEDICATION MANAGEMENT AND REFILLS:

• Refill requests should be made at least 3 – 5 business days in advance of medication running out. The Stratford Clinic requests that follow-up appointments be scheduled to coincide with medication refill needs. If continued last-minute refill requests are made, The Stratford Clinic reserves the right to terminate care of the patient.

• While it is not the intent to have you have any lapse in medication(s), The Stratford Clinic will not refill medication(s) if you have failed to make regular follow-up appointments and reserves the right to terminate care of the patient.

• Prescriptions may only be called in for patients who are current patients and who maintain their regularly scheduled appointments. For your safety, medication refills will not be called in over the weekend except in emergencies.

• Please see the fee schedule for information regarding medication refills and prior authorizations.

MEDICAL RELEASES OF INFORMATION:

For the purposes of patient safety, every patient who is prescribed medication by The Stratford Clinic is required to sign a release of information that permits the patient’s provider at The Stratford Clinic to request the most recent history and physical, problem list, and medication list from any other medical practitioner who is prescribing the patient medication. The release will also allow The Stratford Clinic to provide that practitioner with the medications being prescribed by the patient’s provider at The Stratford Clinic.

TRANSFER OF CARE OR TERMINATION:

• If you decide to transfer care to another provider or resume care with your primary care provider, please inform The Stratford Clinic of this in writing.

• The Stratford Clinic reserves the right to terminate care of a patient for any reason. In this event, you will be provided with one (1) month of medication (if indicated) and can request a list of local providers, however, their availability is not guaranteed.

• If a patient exhibits abusive and/or harassing behavior towards a provider, their care will be terminated at The Stratford Clinic.

• If you have more than two (2) no-shows or same-¬day cancellations, you may be referred to another local provider.

• If you fail to show up for an intake appointment, you may be referred to another local provider. You will be charged for canceling within 24 hours of your appointment or for not attending your appointment.

LEGAL WORK:

Any legal work is performed at a rate of $2000/hour. This includes but is not limited to letters for court or to attorneys, dispositions, testimonies and any other work where court proceedings are involved. Time includes the hours necessary for transportation and preparation for any legal work as well as wait time for court proceedings. Additional billing criteria will be discussed in person. Minimum fee is $2000 and billed in 15-minute increments. Any testimony is at a minimum of 5 hours on the day of testimony; this is in addition to time mentioned above for preparation. Please discuss with the Chief Medical Officer for additional details. All fees/legal work must be paid in advance by retainer with amount to be detailed on a case-by-case basis.

RECORDS:

Legal and professional standards require that your provider keep Protected Health Information about you in a clinical record. These records are kept in a secured file cabinet and/or secured digital filing according to legal requirements. These records help ensure the quality and continuity of your care, as well as provide evidence that the services you receive meet the appropriate standards of care. Your records are maintained in an electronic health record that includes several safety features to protect your personal information, including advanced encryption techniques to make your personal information difficult to decode, firewalls to prevent unauthorized access, and a team of professionals monitoring the system for suspicious activity. Records are maintained for 7 years per Colorado Statute, (7 years after the age of 18 for minors), and then safely destroyed. Attempts to procure your records after this period may be impossible. Providers at The Stratford Clinic PLLC do not process or complete disability insurance claims, nor life insurance claims.

CHANGES TO THE TERMS OF THIS NOTICE:

We can change the terms of these policies, which will apply to all information we have about you. The new policies will be available upon request and accessible at www.stratfordclinic.com.

ACCEPTANCE OF POLICIES:

Your provider at The Stratford Clinic is committed to providing professional services of the highest quality and standards. In order to serve our patients efficiently and responsibly, we require agreements be made as to the policies stated above. Patients/guardians are encouraged to ask any questions related to this document before signing.

Your signature indicates that you have read the policies as outlined above, understand, and agree with them

COMPLAINTS:

If you feel your Provider has engaged in improper or unethical behavior, you can talk to them, or you may contact the licensing board that issued your Provider's license, your insurance company (if applicable), or the US Department of Health and Human Services.