1. CONFIDENTIALITY: This is described in the Privacy Policy. Please note that we value communication with your other healthcare providers and will attempt contact by phone. If for any reason you prefer that we not contact your primary provider, please let us know in writing.

2. AVAILABILITY: We are available by phone for emergencies related to Heading Health’s treatments by calling our main line at 855-204-2502 during regular business hours (Monday-Friday, 8:00am-6:30pm). If you require immediate assistance after regular business hours, please dial 911 or visit your nearest emergency room.

Below are some resources providing emergency services:

National Suicide Prevention Lifeline - 24/7
Call 1-800-273-8255 or

Suicide & Crisis Lifeline:
Dial 9-8-8

Veteran’s Crisis Hotline - 24/7
Call 1-800-273-8255

3. SCOPE OF TREATMENT: The providers of Heading Health may be serving either in a
consulting role to your primary psychiatrist or, in some cases, as your primary psychiatrist. When a Heading Health provider is providing treatment in a consulting role, patients should establish or maintain a treatment relationship with a prescriber (e.g. psychiatrist or primary care physician) and therapist.

4. DRIVING: After receiving a ketamine injection or Spravato, our discharge instructions include no driving until the next day. Any patient who disregards this instruction does so at their own risk and liability.

5. RESEARCH: In order to expand the knowledge base in mental health and work toward new treatments, we anonymously collect demographic, measurement scale, and treatment data for research purposes. If you do not wish to have your information included in anonymous analysis, please notify us in writing, and you will be opted out.

With your electronic consent & submission, you agree to begin treatment with the policies above.

I have read and agreed to the Agreement to Treatment Policy.

Regarding Insurance:

If your intent is for Heading Health to submit a claim to your insurance provider for the care and treatment you receive with one of your providers, you must provide us with your current insurance carrier’s information, including providing a copy of your insurance card. It is your responsibility to ensure that you provide Heading Health with accurate insurance information and notify us immediately if there is a change in your insurance information. If your insurance coverage cannot be verified at time of services, you will be responsible for the full payment of services received.

If we are enrolled with your insurance plan:

· If your insurance requires a treatment referral from your Primary Care Physician, you are responsible for obtaining the treatment referral to our office prior to scheduling your treatment. Failure to obtain the required referrals may result in a denial of payment from your insurance carrier, thereby making you solely responsible for the entire balance owed for your treatment.

· If your insurance requires you to share financial responsibility (i.e. Copayment obligations, patient responsibility, deductibles, and coinsurance) for your treatment, your financial responsibility will be collected at time the treatment was rendered. Regardless of the amount that is collected at the time of your treatment, you must pay all amounts dictated by your insurance carrier as your financial responsibility and will be billed for any additional monies owed.

If we ARE NOT enrolled with your insurance carrier:

· You will be required to pay in full for your treatment at the time of your visit. Requests for an itemized receipt for the treatments rendered must be requested in advance to the practice’s office staff when the appointment is made.

· As a courtesy, we will submit a claim for payment of treatments rendered to your insurance carrier unless you direct us not to. As an out of network provider, we will request that any payments made by your insurance carrier will be made directly to you.

If you are not sure whether we are an enrolled provider with your insurance carrier, please make inquiry with our office staff or contact your insurance carrier to verify network participation.

Cancellation/No-Show Policy:

Appointment times are scheduled and reserved just for you. If you know there is a problem with your appointment time, please call to reschedule as soon as possible. We require at least 48-hours’ notice for cancellations to avoid being charged a no-show/late fee.

If you do not show up to your scheduled appointment or call to cancel within 48-hours of your appointment, you will be charged a $100 fee for each occurrence. More than three no shows could result in being discharged as a patient from the practice. If you call after business hours, please leave a message indicating that you need to cancel or reschedule your appointment.

Forms Fee:

There is a fee of $25 per form for completing disability and/or insurance forms. Payment for generating these forms is due with your request and the form is provided to our office. Please allow up to 5 business days for the completion of any forms.

Medicare Patients:

You must provide us with a copy of your Medicare identification card, as well as a copy of any secondary or supplemental insurance you have that may provide coverage for your treatment (where applicable).

You will be required to satisfy your annual $198.00 Medicare deductible and pay your 20% coinsurance if you do not have a secondary or supplemental insurance. If you have provided us with a copy of your Medicare identification card, and other secondary or supplemental insurance cards, we will not require payment at the time of your treatment as we will be submitting claims for payment to those carriers. You will be billed for any balance owed that your insurance carriers have determined to be your financial responsibility.

Medicaid Patients:

We are not contracted with any type of Medicaid Plans. If you have Medicare as your primary insurance and Medicaid as your secondary insurance, unfortunately, we are unable to treat you.

Regarding Lab Charges:

There will be an additional fee charged by an outside lab for the processing of any labs taken in our office. The professional component of reading/interpreting the results will also be billed separately by an outside lab.

About non-covered services:

A service considered by your insurance carrier to be non-medically necessary (i.e. cosmetic or otherwise) will not be covered by your insurance policy. You will be required to pay in full for these types of services in advance of your treatment unless arrangements have been made with our office administrator.

Thank you for taking the time to read and understand our practice’s financial policy. We are here for any questions or concerns you may have.

 

I attest that I have read the Financial Policy and was provided an opportunity to ask any questions that I had about this policy. I further attest that I understand and agree to all the terms and conditions found in this policy.

By accessing this Portal, you, the patient, understand that this Patient Portal is NOT to be used for urgent or emergency situations and should be limited to non-emergency communications and requests. In case of an emergency, call 911 or go to the nearest emergency room. Here are additional Emergency Services for your reference:

Below are some resources providing emergency services:

National Suicide Prevention Lifeline - 24/7
Call 1-800-273-8255

Suicide & Crisis Lifeline:
Dial 9-8-8

Veteran’s Crisis Hotline - 24/7
Call 1-800-273-8255

You may leave a non-urgent message on this Patient Portal. This Patient Portal is not intended to replace an office visit. Please do not send messages through the Patient Portal that require immediate medical attention. You will receive a response to your non-urgent message within 48 hours on weekdays or on a Monday after a weekend. If you DO NOT receive a response within 72 hours you should contact the practice.

Informed Consent:

You understand that the terms and conditions of this disclaimer and user agreement may change periodically. Such modifications will take effect immediately upon posting on the website. The Patient Portal is a secure HIPAA-compliant communication tool that is provided as a courtesy to our patients and their parents. By agreeing to the terms below, you confirm that you have read, understand, and agree to comply with our procedures and guidelines for using the Patient Portal.

Privacy and Security:

The Patient Portal or webpage has a secure tunnel connection with our practice that uses encryption to keep unauthorized persons from being able to access and read your health information or your communications to us. To help ensure that the tunnel remains secure, we need to have your current (private) email address and be informed if it ever changes. Keep your portal user ID and password secure so that only you, or someone authorized by you, can gain access to patient information. You represent and warrant that all information you provide or supply to the Patient Portal, including without limitation, your registration information, is accurate and complete. You are responsible for the security of your password(s) and for authorizing, monitoring, and controlling any access and use of your account and password(s). You must promptly notify the practice of any unauthorized use of your account or password(s). Communication via the Patient Portal may be included in your permanent medical record.

Heading Health and its affiliated healthcare providers may arrange for you to connect with providers using audio/video technology to communicate and conduct a patient visit with the provider. If you have any questions about the use of telemedicine technology itself or any of the information below, please ask your provider.

1. I understand that I will engage in a telemedicine consultation.
2. A Heading Health representative has explained to me how the video conferencing technology will be used to conduct the consultation. I understand that this is different than a direct patient/health care visit because I will not be in the same room as my health care provider.

3. By using the video conferencing technology, I understand and agree there are risks associated with it, such as:

a. Information that you transmit may be insufficient to allow for appropriate medical decision-making by the provider.

b. Failures of equipment including interruptions, unauthorized access, and technical difficulties.

c. Unauthorized access to your medical information. I acknowledge that, although the facility and its telehealth technology vendor strive to prevent unauthorized access to information about me through encryption and other security measures, the facility and vendor cannot guarantee that your use of the technology and the information will be private or secure, and you consent to this risk.

4. I understand that I am not permitted to record the telemedicine sessions.

5. I understand that I am expected to conduct the telemedicine sessions from a consistent, private location that has been shared with the provider and that it is my responsibility to inform the provider if that location has changed.

6. I agree that to safely treat me in my home, I will be asked to provide contact information for an emergency contact and/or a "Patient Support Person".

7. I understand that given some limitations of non face-to-face contact appointments, Heading Health telepsychiatry providers may decide that they are unable to provide care to me in this way either following consultation or during treatment. Also, due to federal regulations, Heading Heath will be unable to prescribe controlled substances during telepsychiatry visits conducted outside of Heading Health Centers (i.e. in my home).

8. I have been informed of the provider’s availability outside of scheduled visits. I understand that the provider is available by phone for questions between appointments and that the best attempts will be made to return calls within 24 hours. For emergencies, I am to contact my local emergency department, crisis center, 911, or suicide hotline.
You understand and consent to the risks associated with your use of video conferencing technology.

9. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider to operate the video equipment. Those people will all maintain the confidentiality of the information obtained.

10. To expand the knowledge base in mental health and work toward new treatments, we anonymously collect demographic, measurement scale, and treatment data for research purposes. If you do not wish to have your information included in anonymous analysis, please notify us in wring, and you will be opted out.

11. You acknowledge and agree that you are solely responsible for ensuring that the information submitted or transmitted by you through the video conferencing technology is accurate and complete. You understand that the provider will rely on this information to diagnose and prepare a treatment plan for your medical condition and your failure to do so may lead to a delay in your treatment, misdiagnosis, or incorrect submission of billing/claims.

12. I have had the alternatives to a telemedicine consultation explained to me, including having a traditional face-to-face visit with a provider. I also understand that I have the right to stop the telemedicine visits at any me and revoke this consent. Upon revocation, I understand I may not be able to continue to receive care using the telemedicine technology.

Click here to view our Privacy Policy