Policies and Procedures Agreement

Welcome to Mindful Mental health. This agreement includes information about my company policies procedures, business practices and professional services. It also contains summary information about Health Insurance Portability and Accountability Act (HIPAA). The law requires that I obtain your signature acknowledging that I have provided you with this information. Please read this entire agreement carefully. We can discuss any questions you have about anything included in this agreement. When you sign this agreement, it will represent and agreement between you and Blair Crouse, NP-C, owner of Mindful Mental Health. You may revoke this agreement in writing at any time. The revocation will be binding unless you have not satisfied any financial obligations you have incurred, or I have obligations to process or substantiate or process claims made under your insurance policy.

PSYCHIATRIC/PSYCHOLOGICAL SERVICES

All visits are conducted via telehealth. Psychiatric medication management is a component of the treatment plan you and I will develop. Developing a treatment plan will be a shared decision-making process. I value your input and honesty about what you think may help you and why. Knowing all your clinical information is essential to safe and effective management of medications. I require my patients to provide psychiatric history, medical history, and relevant family history as well as current symptoms. I may request that you sign a consent to release information to enable me to request your records, labs, etc. from other providers, including your primary care provider. It is extremely important that you keep an open dialogue with me about how you are tolerating the medications, so appropriate adjustments and interventions can be made. Please remember to inform me of any changes to your medical condition or medication for other medical conditions. All medications are to be taken as prescribed. If you would like to adjust the dose or stop a medication prescribed by me, this needs to be communicated through a message in the portal or a voicemail message requesting a call back to discuss. I will not be able to provide medication management to anyone who repeatedly does not take the medications as agreed upon and prescribed.

I provide brief psychotherapy that is integrated into your medication management visit. Therapies we may use include CBT, DBT, mindfulness, meditation. This is a supplement to individual psychotherapy you may be receiving from a licensed psychologist or clinical social worker. If you are interested in oneon-one or group meditation sessions with me (not covered by insurance), please contact me through
email to discuss. I am in the process of earning certification as a meditation instructor and may be offering this in the future.

APPOINTMENTS

New patients are not guaranteed an appointment at Mindful Mental Health, PLLC. All new patients will be sent an intake form to complete and may have a brief phone intake before an appointment is made. If you are unable to keep your first appointment, please notify me by text, phone, or email immediately. This time is reserved exclusively for you. All forms need to be completed and signed, including method of payment prior to the appointment. If an appointment is cancelled, rescheduled, or missed without 24 BUSINESS hours’ notice (including your first appointment), your method of payment will be billed $75.00 for the session. Insurance does not reimburse for missed visits. If you are more than 10 minutes late to an appointment, you will be asked to reschedule and charged the
missed appointment fee.

Exception: If you are having trouble connecting to the telehealth appointment, please text or call me at 336-355-7013 immediately. If we are unable to resolve a poor connection issue and have had connectivity for at least 10 minutes, the visit can be finished by phone if this is acceptable to you. If the connectivity problems persist for multiple visits, we will discuss whether the telehealth appointments are the right platform for you to see me, and I can refer you to another provider who offers in-person visits. Every effort will be made on my part to resolve the connectivity issues. I do not expect this to be a problem for most visits.

You will receive appointment reminders through an automated system. Reminder calls, texts or emails are a courtesy of Mindful Mental Health, PLLC, and failure to cancel without 24 hours’ notice will result in a fee, as state above.

INSURANCE/PAYMENT

Payment of all applicable copays, co-insurance (or any other amount not covered by your insurer) is required at the time services are rendered and may be made by credit or debit card (including FSA card), Venmo. All balances on your account will be charged to your payment method on file before each visit.

I am in the process of becoming a participating provider with BCBS, which has been delayed by Covid19 and I have been assured I will have a contract with BCBS by April 2021. In the meantime, I will make every effort to work with you to find a fair arrangement for both of us until I am a participating provider. I will perform a verification of benefits with BCBS prior to each visit.

Current Options for BCBS members only:

1) You may pay the full visit fee (see Fee Schedule below), file a “Superbill” yourself, which can be found on my patient portal, and be reimbursed by your insurance company directly. It may be processed as “out of network”. I have been told by BCBS a member can request that it be paid as if I am an “in-network” provider since I am in the process receiving a contract. This has not been tested yet, and I would not count on it.

2) If you arrange with me prior to or at the time of the visit, you may pay your usual co-pay and coinsurance fee for a visit, and no claim will be filed.

Once I become a contracted participating BCBS provider, you will be expected to pay applicable copays, co-insurance, deductibles. As of March 24, 2020, many insurers have eliminated cost-sharing on telehealth visits, such that deductibles do not have to be met before insurance will cover a telehealth visit. Check with your individual insurance policy to see if this applies to your coverage.