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THIS Treatment Contract (this “Contract”) is made effective for all purposes and in all respects as of date undersigned by and between INTEGRATIVE BEHAVIORAL HEALTH & MEDICINE, INC. (hereinafter the “IBHM”) and the undersigned patient (hereinafter the “patient”)
Initial Consultation: The initial consultation is a 45-90 minute face-to-face assessment. All appropriate intake paperwork must be completed prior to your initial consultation. During the initial consultation, the IBHM provider will obtain a comprehensive history and determine whether our clinic can meet your treatment needs. This session is also an opportunity for both you and the provider to assess your mutual compatibility for an ongoing treatment relationship. Depending on the complexity of your case, a second consultation may be required to complete the assessment, determine treatment fit and/or make treatment recommendations. Medications may or may not be prescribed during the initial consultation(s).
Privacy: IBHM will not disclose details of your treatment or your medical record(s) to third parties without your written consent. IBHM operates in accordance with HIPAA laws. You understand that if you are not the payer for services rendered, matters related to billing may be discussed with the payer. You also acknowledge that you have received notice of the privacy policy.
Payment: Credit card information and/or bank information will be obtained prior to your initial consultation. You will be charged before each appointment with your IBHM provider according to the fee structure outlined in the Financial Policies. If you have insurance, IBHM will charge you the appropriate co-insurance or co-payment as derived from your insurance company’s eligibility database. If after charging for the co-payment or co-insurance, IBHM comes to know through your insurance's Explanation of Benefits that the amount due is greater or less than the amount originally charged to you, IBHM will appropriately bill you for the difference and/or refund the excess amount to your patient account as applicable. Neither IBHM nor its providers are liable for any co-pay, co-insurance, or other obligations reported to our office by your insurance company. Should you have questions regarding your coverage, please contact your insurance carrier for details. If you seek reimbursement from an insurer, IBHM may submit claims on your behalf at your request (see Financial Policies for further information).
Late, Missed Appointment and Cancellation Policies: If you arrive too late to allow time for proper care, you may be asked to reschedule. If you are more than 15 minutes late to your appointment, you will be asked to reschedule. Missed appointments prevent you from receiving proper care and prevent the provider from providing that care. Missed appointments also prevent another person from receiving care during that time. You will be financially responsible for the cancellation fee (refer to the Financial Policies for cancellation fee schedule).
Medication Refill Policy: If you need a medication refill, please send us an email with your full name, date of birth, the name of your medication and dose to [email protected]. We receive multiple automated requests each day from pharmacies and it is difficult to determine which requests are appropriate or urgent. Please allow five (5) business days for your request. If it is an urgent request, please mention so in the email and we will prioritize it. Controlled substances will not be prescribed or refilled if you are seeing a provider via Tele-psychiatry only.
Please note that our providers at IBHM are licensed to practice in the State of California and they are unable to order/prescribe controlled medications to any pharmacy outside of California.
Paperwork Policy: Please note that our providers at IBHM do not accept forensic cases. We respectfully decline to see clients who only seek completion of their paperwork (disability paperwork, FMLA, etc.) at the initial consultation or within 2-3 sessions following the initial consultation. Our providers might help you with supportive paperwork, only at their discretion and after establishing care with the client over a period of 3-6 months (if they find it appropriate and deem it necessary).
IBHM psychiatrist and therapist will charge you separately for any paperwork they complete based on the time spent to complete that paperwork. Charges for paperwork are out of pocket and entirely your responsibility. To learn more about the charges please refer to the Out-Of-Pocket section of our financial policy in the documents section of patient portal (https://app2.luminello.com/portal/documents).
Disclosures: If you are a danger to yourself or others or if a provider suspects abuse towards a child, disabled adult or the elderly, providers are ethically and legally required to report it to the appropriate authorities.
Legal Issues: In order to safeguard the process of treatment, our providers do not release patient records except in response to subpoenas from law enforcement or as compelled by court order. Providers do not accept gifts from patients or participate in business deals with patients.
Emergencies: If you have an urgent matter or emergency after normal business hours, on a weekend or on a holiday, we encourage you to call 911, visit the nearest emergency room, or contact your primary care physician (PCP) for immediate assistance. Any messages left for IBHM providers will typically be responded to within one (1) business day.
Controlled substance policy: Please take extra precaution when handling a prescription of controlled substances (as per the DEA definition of a controlled substance) such as opiates, stimulants, sedative-hypnotic agents, etc. IBHM reserves the right to refuse fulfilling early refills or to replace lost prescriptions. If abuse or misuse is suspected, we may discontinue care and refer you to an appropriate provider for follow up services. It is your responsibility to notify your provider of ALL prescription medications you are prescribed and taking. If there is any evidence that you have been receiving controlled prescriptions from multiple physicians without informing your IBHM provider, we reserve the right to discharge you from the clinic immediately. In such case, if you are concerned for your health or safety, you should call 911, visit the nearest emergency room, or contact your primary care physician (PCP) for immediate assistance.
Special notice for patients taking controlled substances: Arriving late for appointments, canceling appointments when important compliance issues need to be discussed, or calling for refills after missed/canceled appointments may be construed as non-compliance and you may be discharged from IBHM due to such behavior.
Clinic discharge policy: IBHM reserves the right to discharge patients from the clinic for various reasons including but not limited to:
Multiple missed appointments or late cancellations.
Patient non-adherence to the treatment plan.
Breach of trust in the patient-doctor or patient-therapist relationship.
Non-payment of fees owed to IBHM.
If you fail to follow up with your provider for more than 6 months (3 months if you are taking controlled substances), without prior approval from provider or have more than three (3) cancellations or missed appointments within a twelve (12) month period, you will be in breach of compliance with your treatment plan and you will be subject to automatic discharge from IBHM as a patient. You may return to the clinic only with authorization from a provider.
If prescriptions are lost or you have run out early more than once in a one (1) year period, we may decide to discharge you from the clinic and refer you to an appropriate provider as necessary.
If there is any evidence that you have been receiving controlled prescriptions from multiple physicians without informing your IBHM provider, we reserve the right to discharge you from the clinic immediately.
Threatening or abusive behavior towards providers.
Non-adherence to IBHM after-hours communication policies.
Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. The interactive electronic systems used in Telepsychiatry incorporate network and software security protocols to protect the confidentiality of patient information and audio and visual data. These protocols include measures to safeguard the data and to aid in protecting against intentional or unintentional corruption. A patient needs to provide their physical address mandatorily consistent with safety protocols and must be in the state of California at the time of appointment.
Potential Telepsychiatry Benefits:
Increased accessibility to psychiatric care.
Patient convenience.
Potential Telepsychiatry Risks:
As with any medical procedure, there may be potential risks associated with the use of Telepsychiatry. These risks include, but are not limited to:
Information transmitted may not be sufficient (e.g., poor resolution of video) to allow for appropriate decision-making by your provider.
Your provider may not be able to provide medical treatment using interactive electronic equipment or provide for/arrange for emergency care that you may require.
Delays in medical evaluation and treatment may occur due to deficiencies or failures of the equipment.
Security protocols can fail, causing a breach of privacy of confidential health information.
A lack of access to all the information that might be available in a face-to-face visit, but not in a Telepsychiatry session, may result in errors in judgment.
Alternatives to the Use of Telepsychiatry:
Traditional face-to-face sessions in your provider’s office.
Patient’s Rights to the use of Telepsychiatry:
I understand that the laws that protect the privacy and confidentiality of medical information also apply to Telepsychiatry.
I have the right to withhold or withdraw my consent to the use of Telepsychiatry during the course of my care at any time. I understand that my withdrawal of consent will not affect any future care or treatment.
I have the right to inspect all medical information that includes the Telepsychiatry visit. I may obtain copies of this medical record information for a reasonable fee.
I understand that my provider has the right to withhold or withdraw consent for the use of Telepsychiatry during the course of my care at any time.
I understand that the all rules and regulations that apply to the provision of healthcare services in the State of California also apply to Telepsychiatry.
Patient’s Responsibilities to the use of Telepsychiatry:
I will not record any Telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our Telepsychiatry sessions without my written consent.
I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for Telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I must be a resident of the State of California and be physically present in the State of California to be eligible for Telepsychiatry services from my provider.
I understand that my initial evaluation will not be done by Telepsychiatry except in special circumstances under which I will be required to verify my identity.
I understand that controlled substances cannot be prescribed to me while seeing a provider via Telepsychiatry unless I am seen in-person by a provider in IBHM.
I understand that Telepsychiatry can only be provided to me by IBHM providers while I am physically located in California.
I understand that in the event I am outside of the state of California, I will inform my provider at IBHM proactively.
Patient Consent to the use of Telepsychiatry:
I have read and understand the information provided above regarding Telepsychiatry. I have discussed it with my provider and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of Telepsychiatry in my health care and authorize my provider to use Telepsychiatry in the course of my diagnosis and treatment.
We respect the rights of individuals to voice their opinion regarding our providers and services. However, we request that prior to posting any negative reviews or comments on any forums, websites, and/or public databases, you contact our office at [email protected] to voice any concerns or issues you are facing so we may have the opportunity to resolve any conflicts.
READ THIS MUTUAL BINDING ARBITRATION AGREEMENT CAREFULLY BECAUSE YOUR SIGNATURE BELOW CONFIRMS THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO THE TERMS OF THIS MUTUAL BINDING ARBITRATION AGREEMENT.
You and IBHM understand and agree that this binding Arbitration Agreement (“Agreement”) applies to all claims (the “Arbitrable Claims”) arising out of, related to or connected with any services provided to you by IBHM. For purposes of this Agreement, the term “Arbitrable Claims” shall be deemed not to include any claims which by law cannot be subject to a contractual requirement of mandatory binding arbitration. You and IBHM (the “Parties”) hereby agree that arbitration shall be the exclusive method by which to resolve any Arbitrable Claims, and specifically agree that the Parties will not file a lawsuit in court to pursue any Arbitrable Claims. Arbitration shall be final and binding upon the Parties. THE PARTIES HEREBY WAIVE ANY RIGHTS THEY MAY HAVE TO TRIAL BY JUDGE AND/OR JURY IN REGARD TO ARBITRABLE CLAIMS.
Binding arbitration under this Agreement shall be conducted in Santa Clara County, California before a neutral arbitrator selected and agreed to by both Parties. If the Parties are unable to agree, they shall each select two arbitrators from the list of arbitrators published by the American Arbitration Association (“AAA”) and submit their selection to AAA who shall appoint the arbitrator based on availability. The arbitration shall be conducted in accordance with AAA’s written rules and procedures which can be obtained from the AAA website at: www.adr.org. Nothing in this Agreement shall prevent the Parties from mutually agreeing to submit their dispute to mediation. If the dispute is not resolved through mediation, it shall be submitted to binding arbitration pursuant to the terms of this Agreement. The Parties understand and agree that they will split the cost of the arbitrator’s fee so that each party is responsible for paying equal amounts for the arbitration. The Parties shall each pay their own attorneys’ fees and costs incurred in connection with the arbitration, and the arbitrator will not have the authority to award attorneys’ fees unless a statute or contract at issue in the dispute authorizes the award of attorneys’ fees, in which case the arbitrator shall have the authority to make an award of attorneys’ fees as required or permitted by applicable law. Each party enters this Agreement knowingly, and voluntarily, in the total absence of fraud, mistake, duress, coercion, or undue influence and after careful thought and reflection upon this Agreement; and accordingly, by signing this document, each Party signifies full understanding, agreement and acceptance. The Parties have read this Agreement carefully and understand that by signing it, they are waiving all rights to a court trial or hearing before a judge or jury of any and all disputes and claims subject to arbitration under this Agreement.
1. Medical doctors are licensed and regulated by the Medical Board of California, (800)633-2322, www.mbc.ca.gov.
2. The Department of Consumer Affairs’ Board of Psychology receives and responds to questions and complaints regarding the practice of psychology. If you have questions or complaints you may contact the Board on the internet at www.psychology.ca.gov, by e-mailing [email protected], calling 1-866-503-3221 or writing to the following address: Board of Psychology 1625 North Market Blvd, Suite N-215 Sacramento, CA 95834.
Our clinic policies are subject to change and you will be notified of these changes as they arise. IBHM reserves the right to make changes to clinic policies at any time.
To view our most recent policies, please visit the policies page at - https://integrativebehavioral.com/policies