Disclosure of Health Information

Patient Information

Health Information

I understand that this authorization may be revoked by me at anytime (with the exception that Mercyland Psychiatry has already acted in reliance on it) by written notice. I have the right to inspect and receive a copy of the material to be disclosed and receive a copy of the informed consent. This consent will remain in effect until the above request is processed or unless otherwise specified. When health information is disclosed to anyone except a covered facility it would no longer be protected under HIPAA (Health Insurance Portability and Accountability Act of 1996) regulations. Signing this authorization is voluntary and I may refuse to sign. Unless allowed by law, my refusal to sign this authorization will not affect my ability to obtain treatment, receive payment, or eligibility for benefits.

Prohibition of Disclosure: This information has been disclosed to you from records protected by Federal confidentiality rules (42CFR Part 2 and Wisconsin Statute 51.30). The Federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. I understand I may inspect and receive a copy of the disclosed information.

I understand a photocopy of this consent is as valid as the original. This consent is valid for a period of one (1) year.


For minors


New Patient Packet

Introductory Letter

Dear Patient or Parent/Guardian,

Thank you for contacting Mercyland Psychiatry and for your willingness to establish care with us.

We constantly strive to provide quality and compassionate care to our patients and caregivers. In an effort to help us serve you better there are requirements in the form of checklists and/or questionnaires which need to be completed and brought to the clinic with you for your initial appointment.

The list of forms, checklist, and/or questionnaires that are required are as follows:

1) Health Assessment form
2) ** Child/Adolescent Health Assessment form
3) ** Child Behavior Checklist, Parent, and Teacher Version (Two copies of each)
4) ** Child Behavior Checklist (For Adolescents ages 11 to 18)
5) ** Authorization for Disclosure of Health Information form (For School/Class teacher)

** Forms 2 though 5 are only applicable to children and adolescents under 18 years of age. It is also the responsibility of the parent(s) and/or guardian, to obtain copies of previous psychiatric evaluations, neuropsychological evaluations, inpatient discharge summaries, and IEP or 504 plans from the school. This will aid in the continuity of care and avoid unnecessary delays in treatment. **

The hours of operation are Monday through Friday 8:00 AM to 5:30 PM. Initial appointments are typically 60 minutes long. In case we are unable to conclude the initial appointment in the stipulated time frame, a followup appointment may be requested and typically lasts 30 to 60 minutes. All subsequent follow-up appointments are 15 to 30 minutes in duration. It is advisable that you arrive 15 minutes prior to your scheduled appointment. This allows ample time to complete any necessary paperwork associated with your appointment. We strive to keep wait times to the bare minimum; however, there may be times in which you may be seen later than your scheduled appointment time.

In the event that you arrive 30 minutes late for your initial appointment or 15 minutes late for your regular follow-up appointment, you may be asked to reschedule the appointment. Please be aware that this is not punitive, but allows us to provide productive and meaningful care to all our patients.

Please feel free to contact us if you have any questions. The phone number is (608) 318-2233.

Again, thank you for choosing Mercyland Psychiatry. We look forward to working with you and your family.

Adebowale Mofikoya, MD

Child, Adolescent, and Adult Psychiatrist

AUTHORIZATION FOR TREATMENT ASSIGNMENT OF INSURANCE BENEFITS RELEASE OF MEDICAL INFORMATION

Aside from the treatment and services you will receive at Mercyland Psychiatry there are some points that we would like to bring to your attention. You should be familiar with and understand the following prior to committing yourself to treatment. Each item should be discussed with you by your provider. If you have any questions, please ask them.

1. Confidentiality: We want you to know that anything you discuss in our office is considered confidential. You should be comfortable discussing your concerns and problems. We cannot share your information with others without your written consent. The exceptions and/or limits to the confidentiality include but are not limited to suspected abuse and/or neglect, threats of suicide, or physical violence, and when the courts subpoena your records.

2. Insurance: Diagnosis and/or billing code number and dates of outpatient treatment sessions will be provided to your insurance carrier for billing purposes. By signing this authorization, you give us permission to do this.

3. Rights: Please read the Patient Bill of Rights document carefully. It outlines your rights in more detail.

4. Complaints: You have the right to voice your complaints regarding your treatment, provider, billing, or other matters.

5. Fees: The cost of your treatment is detailed in the Fee Sheet. We ask that you discuss any fee or billing concerns you have with your provider.

6. Appointments: Your provider will ask you to make appointments at times that are convenient to you. Any cancellation should be made at least 24 hours before your scheduled appointment time. Failure to do so will result in your being charged one-half the provider’s normal fee for a 1 hour session. You may be directly responsible for this fee because insurance companies typically do not pay for missed appointments.

Consent: I freely consent to the treatment offered me by the staff of Mercyland Psychiatry. I am aware of my rights as a patient. I am aware that this authorization will remain in effect while I am in treatment and until payment of services is completed. I understand that I can withdraw this consent at any time by submitting my request in writing.

BILLING INFORMATION

Insurance Information

FEE POLICY

• We strongly encourage you to become familiar with your insurance policy and understand the extent of mental health and/or addiction services coverage. You should check to see the requirements of your plan before your next appointment. The fee allowed or paid by your insurance and the co-pay may vary with the policy or the contract that Mercyland Psychiatry has with your insurance carrier. It is your responsibility to pay any portion of the bill not covered by insurance.

• Co-payment is due at the time of your appointment.

• If you are self-pay, you will be required to pay one-half of the session fee at the time of each appointment and set-up a payment plan.

• Mercyland Psychiatry will not enter into any dispute with your insurance carrier. Should they fail to pay, you are responsible to pay the unpaid balance, in-full sixty (60) days after your appointment.

• An individual may be involuntarily discharged from treatment services for their inability to pay for services under certain circumstances. Mercyland Psychiatry may turn over any outstanding bill to a collection agency if appropriate and adequate payment arrangements are not reached.

• If we can be of any assistance in helping you understand your coverage, please feel free to ask us.

The fee charged for the initial assessment, usually 60 minutes in length, is billed at: $484

Medication evaluation and management will be billed based on complexity at: $100 to $500

If psychotherapy is provided in addition to the medication evaluation and management, there will an additional charge for psychotherapy of: $420 (16 to 60 minutes)

When I am directly involved in providing crisis services the fee is: $400 (60 minutes) | + $200 (per 30 minutes).

• Missed sessions and those cancelled without 24 hours’ notice shall be billed at one-half the session fee.

• Insurance companies and medical assistance generally do not cover this fee.

• If you have more than 2 missed sessions without cause, treatment will be terminated.

I acknowledge that I have read and understand the fee policy information listed above.

HEALTH ASSESSMENT

Primary Care Provider:

Medications (Include vitamins, supplements, and any over-the-counter medications):

Sleep

Nutrition

Beliefs/attitude about food:

Include how much and the reason why.

Behaviors around food:

Exercise:

Smoking:

Alcohol

Cocaine

Heroin

Marijuana

Pills

IV drug use

Firearms

Past/Current Medical Health Issues:

Have you been treated for or experienced the following?

If you answer yes, explain how often you experience the condition, the length of illness, if you are currently being treated and by whom.

Risk Factors for Infectious Disease:

Have you been treated for or experienced the following?

If you answer yes, explain how often you experience the condition, the length of illness, if you are currently being treated and by whom.

Please Circle the Number that Best Matches Your Response:

FINANCIAL POLICIES AND PROCEDURES

At Mercyland Psychiatry, we believe that all patients who are rendered care at this office deserve the best medical care that can be provided. In order for us to provide you with the highest quality medical care and current technology, we must insure that we are able to meet the expenses necessary to operate this facility. To ensure that these expenses are met, we provide you with this Agreement regarding our financial policy and your agreement to pay for services provided. Please sign and date this Agreement on the last page to indicate you accept these terms.

PAYMENT AT TIME OF SERVICE, FEES AND COLLECTIONS

Your insurance policy is a contract between you and your insurance company. We will not become involved in disputes between you and your insurance carrier. We do provide your insurance carrier with information regarding your diagnosis and treatment. We do not get involved in such matters as disputes regarding deductibles, copayments, non covered charges and "usual and customary" charges. If your insurance carrier does not provide payment within 60 days after treatment, you will be responsible for payment. You are responsible for timely payment on your account. We require that you pay any amount not covered by your insurance such as deductibles and copayments under your policy on the day of service. If your plan requires you to pay co insurance, you will be required to pay that. Mercyland Psychiatry, is required in accordance with its contract with your insurer to collect from you deductibles and copayments. We will determine your copay and how much of your yearly deductible under your policy has been met for the year. If you are unable to pay your copayment at check in, another appointment may be made for you. Any additional payment owed will be collected in full at the time of service. If needed, we will work with you to arrange a payment plan.

It is your responsibility to provide us with your current insurance card and photo identification at every visit so that we may bill the insurance company in a timely fashion. It will be reviewed or copied every time you are here for a visit, no matter how frequently you are seen. If a claim is rejected because your insurance does not cover the type of service rendered, you will be held responsible for the outstanding balance. Please call the telephone number on your insurance card before your appointment and they will assist you in finding out whether the service to be provided at the appointment is covered, what your copay is and what your deductible is. It is your responsibility to understand your insurance coverage. If your insurance does not cover the cost of your visit or procedure, you will be responsible for the charges for all services rendered.

Please educate yourself as to your coverage so that office visits, procedures, testing, and specialist referrals may be arranged to best suit your needs.

Once we determine your personal financial obligation or after your insurance company reimburses Mercyland Psychiatry, for a portion of your care, we may mail you one (1) statement. Payment is expected upon receipt of the statement. Any account past due by 30 days or more may be subject to submission to our collection agency. If your account becomes delinquent and is placed into our collection process, collection fees will be your responsibility and added to your balance. Mercyland Psychiatry, reserves the right to discharge any patient at this point. By signing our financial policy, you agree to pay these added fees, along with any and all costs associated with the collection of your account, including interest charges.

If you are seen in our office by a nurse or a medical assistant for minor medical services you may be charged a limited office visit, and applicable co pays will be collected.

If you carry a balance on your account during the time you present at our office, a payment on your account will be required at the time unless a Credit Card is kept on file or a payment plan is in place. Mercyland Psychiatry, reserves the right to terminate any patient who misses a payment. Under unusual circumstances, we are willing to work out personalized payment schedules if you so require and can demonstrate need. We accept cash, check or credit card.

CREDIT CARD ON FILE

You may no longer receive bills from our office in the mail. We may require a credit or debit card on file with our office. Statements are wasteful of paper, stamps, and envelopes and are not efficient. We need to ensure that we have a guarantee of payment on file in our office. Times are changing in healthcare, and we need to be sure that patient responsible balances are paid in a timely manner. We have to be fair and apply the policy to all patients. We have wonderful patients and we know that most of you pay your balances. Unfortunately, this is not the case every time.

You will receive a letter in the mail from your Insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits, or EOB. This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay. We receive the same letter that you do. It arrives about 20 to 30 days after your appointment. We look at each Explanation of Benefits (EOB) carefully, and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a bill for in the mail.

We do not store your sensitive credit card information in our office. We store it in a secure fashion with a reputable financial firm called payjunction. We access your information only on this site to process a payment. You will be required to sign a credit card on file authorization statement that will allow us to charge an amount agreeable to each of us until your balance is paid in full.

We will always work with you to understand if there has been a mistake, and we will refund you if we have made a billing error. We will only charge the amount that we are instructed to by your insurance carrier, in the letter they send to us and the amount that you have agreed to, in the same way that we normally determine how much to send you a bill for in the mail.

ELECTIVE PROCEDURES/NON COVERED PROCEDURES

Patients are required to pay the estimated self pay portion of elective/non covered procedures prior to services being rendered base on insurance verification and eligibility of benefits.

SUBMISSION OF CLAIMS

We will submit your insurance claims. However, it is important to remember that your insurance is a contract between you and your insurer. Although we file insurance claims as a courtesy to you, you are still responsible for payment of services regardless of the amount your insurance pays.

PAYMENT OPTIONS

Our office accepts most credit and debit cards. Our office also accepts valid check or cash. There will be a $50 fee for all returned checks. Once we have a returned check for you, we may require that all future payments be with cash, money order, cashier’s check or credit card. Anytime a co pay, deductible or balance is due, we will charge the fee to your credit card which will help to keep you at a zero balance and paid up in full with your credit card on file.

CASH PAYMENT

If you wish to pay cash, you will always be provided with a receipt so that you will have a record of your payment. Please make us aware if you are not provided a receipt.

MEDICARE PATIENTS

If you have Medicare as your primary insurance carrier, but you do not have a secondary insurance, you are responsible for the deductible, copay and co insurance at the time of service. You are also responsible to pay for services not covered by your Medicare insurance unless you have a secondary insurance. You will be required to sign an Advanced Beneficiary Notice for non covered services.

NON-CONTRACTED INSURANCE (Out of Network)

If you have an insurance plan that we do not participate with, you may have out of network benefits. These benefits typically have a higher copay, coinsurance, and/or deductible out of pocket cost. You will be considered a self pay, uninsured patient if you do NOT have out of network benefits.

UNINSURED/SELF PAY

We offer a discount to all self pay patients who pay in full at time of service. Payment is expected at each visit. All other ancillary, treatment and future care will be reviewed with you in order to make arrangements for payment.

MISSED APPOINTMENTS/NO SHOWS/LATE FOR APPOINTMENT

We understand that you may not be able to keep all of your scheduled appointments or might occasionally be late. Please understand that missed appointments have a detrimental impact on our practice and other patients. They also affect our ability to serve other patients in need of medical care. We understand there may be inclement weather or other circumstances that may require you to cancel your appointment. If you must cancel or re schedule your appointment, please do so at least 24 hours in advance. Failure to cancel or reschedule an appointment at least 24 hours in advance will be considered a no show. We reserve the right to charge you $50.00 for any no show if permitted by law and your insurance contract. Payment of the missed appointment will be required prior to scheduling another appointment. Mercyland Psychiatry, reserves the right to terminate any patient with more than two no show appointments upon 30 days written notice to the patient to seek medical help from another practice.

If you are running late on the day of your appointment due to unforeseen circumstances, please contact our office immediately so that we can determine whether we can see you that day or if we will need to reschedule your appointment. If you are more than 15 minutes late for an appointment, Mercyland Psychiatry, may reschedule your appointment and refuse to see you at the originally scheduled time.

REFERRALS

If your insurance carrier requires a referral or authorization for your visit, it is your responsibility to make sure that our office receives current valid authorization. If you do not have a valid referral or authorization at the time of service, we will be unable to treat you until a valid authorization/referral is obtained, and you may be sent back to your primary care physician to obtain authorization prior to being treated or full payment will be expected at the time of service. Please remember that it is your responsibility to make sure we are on your plan's provider listing. We appreciate your understanding of the ever changing requirements of managed care plans and our position to adhere to their policies or requirements.

FORMS AND MEDICAL RECORDS FEES

Due to the increasing costs of providing our patients with the highest standards of care, we must impose a charge for certain records and forms. It takes time for our providers and staff to retrieve and copy files, complete forms and write letters. The following charges apply:

FMLA, Disability, Corps, School forms not completed during an appointment, and Supplemental insurance forms $50.00

Dictated letters, extensive forms with review of medical records $50.00 per page

Copies of records for personal use will be charged the allowed fee by the State of Wisconsin.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize Mercyland Psychiatry: (1) release any information necessary to insurance carriers regarding my illness and treatments; (2) process insurance claims generated in the course of examination or treatment; and (3) allow a photocopy of my signature to be used to process insurance claims for all services provided to me by Mercyland Psychiatry. This order will remain in effect until revoked by me in writing.

I have received the practice’s Medical Authorization for Release / Disclosure of Protected Health Information / HIPAA Privacy Notice.

ASSIGNMENT OF BENEFITS, ASSIGNMENT OF RIGHTS TO PURSUE ERISA AND OTHER LEGAL AND A DMINISTRATIVE CLAIMS ASSOCIATED WITH MY HEALTH INSURANCE AND /OR HEALTH BENEFIT PLAN ( INCLUDING BREACH OF FIDUCIARY DUTY) AND DESIGNATION OF AUTHORIZED REPRESENTATIVE

I hereby assign and convey directly to the above named health care provider, as my designated authorized representative, all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services, treatments, therapies, and/or medications rendered or provided by the above named health care provider, regardless of its managed care network participation status. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the above named health care provider to release all medical information necessary to process my claims. Further, I hereby authorize my plan administrator fiduciary, insurer, and/or attorney to release to the above named health care provider any and all Plan documents, summary benefit description, insurance policy, and/or settlement information upon written request from the above named health care provider or its attorneys in order to claim such medical benefits.

In addition to the assignment of the medical benefits and/or insurance reimbursement above, I also assign and/or convey to the above named health care provider any legal or administrative claim or chose an action arising under any group health plan, employee benefits plan, health insurance or tort feasor insurance concerning medical expenses incurred as a result of the medical services, treatments, therapies, and/or medications I receive from the above named health care provider (including any right to pursue those legal or administrative claims or chose an action). This constitutes an express and knowing assignment of ERISA breach or fiduciary duty claims and other legal and/or administrative claims.

I intend by this assignment and designation of authorized representative to convey to the above named provider all of my rights to claim (or place a lien on) the medical benefits related to the services, treatments, therapies, and/or mediations provided by the above named health care provider, including rights to any settlement, insurance or applicable legal or administrative remedies (including damages arising from ERISA breach of fiduciary duty claims). The assignee and/or designated representative (above named provider) is given the right by me to (1) obtain information regarding the claim to the same extent as me; (2) submit evidence; (3) make statements about facts or law; (4) make any request including providing or receiving notice of appeal proceedings; (5) participate in any administrative and judicial actions and pursue claims or chose in action or right against any liable party, insurance company, employee benefit plan, health care benefit plan, or plan administrator. The above named provider as my assignee and my designated authorized representative may bring suit against any such health care benefit plan, employee benefit plan, plan administrator or insurance company in my name with derivative standing at provider's expense.

Unless revoked, this assignment is valid for all administrative and judicial reviews under PPACA (health care reform legislation), ERISA, Medicare and applicable federal and state laws. A photocopy of this assignment is to be considered valid, the same as if it was the original..

I HAVE READ AND FULLY UNDERSTAND THIS AGREEMENT.

INFORMED CONSENT FOR TREATMENT

In meeting with my provider, I have been given information on the following:

1. The results of the assessment including treatment recommendations and the manner in which the treatment will be administered.

2. The benefits of the treatment recommendations.

3. Possible outcomes and side effects of the treatment recommended.

4. Alternative treatments.

5. The probable consequences of not receiving the treatment recommended in the treatment plan.

6. The approximate duration and desired outcome of the treatment recommended in the treatment plan.

7. My rights in receiving outpatient mental health services, including my rights and responsibilities in the development and implementation of an individual treatment plan.

8. The fees that will be billed for the proposed services.

9. How to use the clinic’s grievance procedure.

10. How to obtain emergency mental health services after our normal operating hours by calling 802-399-9114.

11. How an individual may be discharged from our services:

a. If I display physical or verbal disruptive or threatening behaviors, criminal activity, or I pose a threat to another individual.
b. If I represent myself in a fraudulent manner or provide misleading or inaccurate data.
c. If I repeatedly schedule appointments and fail to maintain the appointment or obligations and responsibilities to attend and/or participate in treatment services.

Consent: I understand that in signing this document I am authorizing Mercyland Psychiatry to provide outpatient mental health and/or addiction services to me as discussed with the treatment provider. This consent shall be in effect for twelve months after the date signed. I understand that I can withdraw this consent at any time by submitting my request in writing.

PATIENT BILL OF RIGHTS

Mercyland Psychiatry is required by law to maintain the privacy of your medical and mental health information. All providers of services in this practice follow the same privacy rules. Whenever, a MD or other provider treats you, medical and or/mental health information is generated. This information may be written (medical record), spoken (providers discussing our health), or electronic (billing information saved on the computer).

• The law permits Mercyland Psychiatry to use or disclose health information for the following activities: treatment, payment, health care operations, communication with you, and in some cases, appointment reminders.

• Examples of permitted uses and disclosures of health information without consent include: child abuse, adult and domestic abuse, mandated clinic review, judicial or administrative proceedings, serious threat to health or safety, workers’ compensation, coroners, medical examiners, and funeral directors.

• Activities that require your written permission (authorization): We must receive your written authorization to release your information for purposes outside of treatment, payment, and healthcare operations.

When you receive services for mental health, alcoholism, drug abuse or a developmental disability as an outpatient, you have the following rights under WI Statute Sec 51.61:

• Treatment Rights and Related Areas:

o To receive prompt and adequate treatment.

o To request restriction on uses and disclosures of your medical or mental health information.

o To be treated in the least restrictive environment possible.

o To be free from having unreasonable or arbitrary decisions made about you.

o To refuse any treatment or medications because of the voluntary nature of therapy, or because your religious beliefs prohibit it.

o To refuse to participate in any drastic treatment or experimental research.

o To be free from unnecessary or excessive medications.

o To be free from physical restraint except in emergencies where you pose a danger to yourself, others, or are damaging property.

• Rights of Access to Court:

o To petition the court for review of any civil commitment proceedings that might be initiated.

o To be considered legally competent unless determined otherwise by a court and to make your own decisions.

o To bring legal action for damages against those who violate your rights.

• Communication and Privacy Rights:

o To refuse to be filmed or taped without your consent.

o To request how we may contact you.

o To inspect and copy your mental health records, medical records, or billing information.

o To request corrections to your mental health, medical, or billing records.

o To receive a list of certain disclosures.

o To have your treatment records and conversation kept confidential at all times (Sec 51.61 WI Stats), information being released only with your written consent, except where you represent a threat to yourself and/or others, or the records are requested by a court of law.

o The treatment professionals affiliated with Mercyland Psychiatry are mandated by law to report instances of suspected child abuse or neglect and/or elder abuse/neglect.

o To have access to your treatment records after discharge and during treatment with the approval of the medical director or his designee and to have access at all times to records of medications prescribed or any treatment you receive for physical health reasons.

• Complaints and Grievances:

o To implement the grievance procedure explained to you by your treatment provider at any time you have a concern or believe your rights have been violated.

o To ask for and receive a copy of the grievance procedure currently in place.

o To contact the complaint investigator or his/her designee and file a complaint or learn more about the process.

▪ Complaint investigator contact information:

• Mercyland Psychiatry, Medical Director
425 W. Main St., Suite 201
Sun Prairie, WI 53590
(608) 318-2233

OR

• Wisconsin Department of Health Services – Division of Quality Assurance
1 W. Wilson St.
Madison, WI 53701
(608) 266-8481

I acknowledge that I fully understand the information listed above.


PHQ-9 Form

Over the last 2 weeks, how often have you been bothered by any of the following problems?

0 = not at all | 1 = Several days | 2 = More than half the days | 3 = Nearly every day