Thank you for choosing Intuitive Minds Wellness, LLC for your mental health care. Intuitive Minds Wellness appreciates the opportunity to provide you with professional services, including Comprehensive psychiatric evaluations, diagnosis and assessment, lab-work, hormonal and digestive assessments, prescriptions and medication management, referrals to health services as appropriate, nutritional supplements, additional holistic therapeutic treatment modalities individualized to client.

It is important that throughout the treatment process you have a clear understanding of why you are receiving services, and how we are attempting to assist you in your mental health care. If you are uncertain about this, you are encouraged to ask for clarification. This Services Agreement explains the office policies, procedures, and practices. Please read this document and any additional hand-outs carefully so that we can discuss any questions you may have.

You will be instructed to sign at the end of this document indicating you have read, understand and accept this agreement along with additional documentation Intuitive Minds Wellness has provided.

Intuitive Minds Wellness reserves the right to change the practices described or terms of this Services Agreement at any time. You may receive any revisions to the Services Agreement by calling and requesting.

Client’s Rights and Complaints Process:

• You have the right to refuse treatment.
• You have the right to change practitioners or receive referral to another practitioner.
• You have the right to review your records.
• You have the right to confidentiality. ***There are exceptions for the reporting of abuse as required by law, dangerousness to self or others, or grave disability. Please see the “Notice of Privacy Practices” (“NPP”).

I understand that if I feel that my rights have been violated, it is my right to file a complaint with the State of Florida. For further information please visit: http//ahca.myflorida.com/hipaa/

Payment in full is due at the time of service unless other arrangements have been made with Intuitive Minds Wellness ahead of time. If you are seeking an out of network insurance carrier reimbursement, you will be expected to pay at time of service and Intuitive Minds Wellness will provide a superbill that you may use to file a claim for reimbursement.

Must have a credit card on file in order to be eligible for services.

Credit card numbers can be retained on file through [our client portal provider, RXNT]
[Intuitive Minds Wellness accepts payments via cash, credit cards (Visa, MasterCard, Discover, and American Express), Apple/Android/Samsung Pay (and other NFC mobile / contactless payments), and EMV chip cards]

Initial psychiatric evaluation $400
Approximately 1-1.5 hours. Includes comprehensive Psychiatric Evaluation, lab work recommendations, medical review, treatment history, family history, prescription (when appropriate), Diagnosis (when appropriate) incorporation of functional/nutritional/holistic recommendations.
1 Hour Follow-Up Visit $220
Addresses more complex conditions, may include additional screenings/assessments, more therapeutic/functional interventions and planning, medication management
30 Minute Follow-Up Visit $150
Used for an established client who is mostly stable, includes therapeutic interventions, integrated treatment, medication management
15 Minute Follow-Up Visit $100
Appropriate for an established client whose condition is stable, seeking simple management of medications

Payment is due at the time of your appointment.

If your account remains delinquent for 120 days or more, Intuitive Minds Wellness reserves the right to discontinue services until full payment is received and/or refer the account to a collection agency.

Intuitive Minds Wellness cannot accept responsibility for collecting on a disputed insurance claim. You are ultimately responsible for full payment on your account.

Out of Network Insurance Carrier Reimbursement
Most clients with PPO insurance (who have met their annual deductible) are typically reimbursed for around 50% of fees.

Your insurance carrier may reimburse you for payments even though our providers are considered “out of network”. If you wish to seek reimbursement from your insurance carrier, your provider can provide you with a signed receipt for services, which contains what would reasonably be expected to be the information necessary for your insurance carrier to process your reimbursement. Clients are responsible for the disclosure of the information contained on such a receipt and for completing any relevant insurance claim form, submitting such claim, and directly seeking reimbursement from their insurance carrier. Intuitive Minds providers are not able to bill Medicare or Medicaid for you.

Please allow 14 days for any records or letter requests. There is a $25.00 fee for any letters requested.

You must inform your prescribing provider of any and all medications currently being prescribed by all other providers.

Before contacting our office, please call the pharmacy directly to ensure that you do not have any additional refills on file, possibly under a different prescription. Please ask the pharmacy “are there any prescriptions under my name” as many pharmacies utilize multiple computer systems to determine if you have any prescriptions on file. We do not respond to pharmacy-generated automated refill requests. If you require additional medication before your next appointment, please contact our office soon as possible. It may take up to five (05) business days to generate your script and you must have a follow-up appointment scheduled; please do not expect that the medication will be filled on the same day as the request.

If you are receiving any type of controlled medications such as benzodiazepines or stimulants. Please note: they will not be refilled early regardless of the reason. Please take your medications as prescribed and keep your medications in a safe spot to avoid this situation

As a general rule, we do not prescribe benzodiazepines to clients, except under rare and specific circumstances (in certain stages of bipolar disorder, or for certain events such as procedures or flying, which are very anxiety provoking). If you are a potential client already prescribed benzodiazepines, then please be aware that our main approach will include a plan to taper you off of the benzodiazepine over a period of time that is both safe and up to our discretion as practitioners.

Must Provide notification of Cancellation 24 hours in advance, if advanced notification not provided, client will be responsible cost of visit; 72 hours advance notice required over weekends. This fee must be paid before any further services are provided. It is necessary to start and end on time. I will do all that is possible to keep appointments on schedule. In the event that you are late for an appointment, please note that we may not be able to run over your scheduled time.

Meetings are based upon individual needs. The frequency of appointments is determined by the individual’s severity of symptoms and response to treatment. When a condition becomes stabilized or reaches maintenance phase, visits may be every four to twelve weeks based on the provider’s professional recommendation and in collaboration with client.

When the business is closed I understand, in the event of an emergency I must call 911 or go to the nearest emergency room. I understand that the provider is NOT on call after hours of business. Intuitive Minds Wellness voicemail has instructions on how to proceed if you have an emergency. If this is a medical emergency call 911 immediately or go to the nearest hospital Emergency Room.

The first appointment is an opportunity for us to evaluate if we will continue a working relationship. If we feel that we will not be able to work together effectively or if you would prefer not to continue in treatment, we will do our best to refer you to other qualified professionals. Treatment is generally terminated when we mutually agree that sufficient progress has been made towards your goals. You are under no obligation to continue treatment if you are dissatisfied or do not feel your treatment is effective. If you feel that you would like to work with another provider for any reason, please let me know and I will be glad to refer you to another clinician who can assume care for you. If in the course of treatment, it becomes clear that another clinician would be more professionally suited to treat your specific needs then I may discontinue treatment and give you referrals to other clinicians. If I conclude I am not able to provide the care an individual needs, I will give you the names of other mental health clinicians qualified to provide treatment for you. You have the right to refuse any recommendations or referrals I may make. I may legally find it appropriate to terminate therapy if it appears your refusal of recommendations may endanger the health of you or others. Please feel free to discuss any concerns you have about terminating treatment.

Intuitive Minds Wellness keeps a record of the health care services provided to you. You may ask to view the records as well as correct the record if you deem necessary. The content of all your medical records are confidential. Your medical record may contain information regarding HIV/AIDS, substance abuse, mental health, sexually transmitted diseases, or other sensitive information. Intuitive Minds Wellness will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so.

If client information is transferred or stored electronically, it will be encrypted to protect privacy. Client records will be kept in a locked filing cabinet when not in use, or in an electronic health record (EHR) system. The EHR used by Intuitive Minds Wellness meets or exceeds all HIPPA and HHS certification requirements, as well as other state and federal regulations.Intuitive Minds Wellness is required by law to report any breach of PHI.

What is a Breach? The HITECH Act added a requirement to HIPAA that medical providers must give notice to clients and to the U.S. Department of Health and Human Services (HHS) if they discover that “unsecured” PHI has been breached. A “breach” is defined as the acquisition, access, use or disclosure of PHI in violation of the HIPAA Privacy Rule. Examples of a breach include: stolen or improperly accessed PHI; PHI inadvertently sent to the wrong provider; and unauthorized viewing of PHI by an employee of Intuitive Minds Wellness. PHI is “unsecured” if it is not encrypted to government standards.

When Intuitive Minds Wellness becomes aware of or suspects a breach, Intuitive Minds Wellness will conduct a Risk Assessment. Intuitive Minds Wellness will keep a written record of that Risk Assessment. Unless Intuitive Minds Wellness determines that there is a low probability that PHI has been compromised, Intuitive Minds Wellness will give notice of the breach.

After any breach, particularly one that requires notice, Intuitive Minds Wellness will reassess its privacy and security practices to determine what changes should be made to prevent the recurrence of such breaches.

Although your health care records in our office are our physical property, the information belongs to you. You may request access to your medical record file, billing records, and other records used to make decisions about your treatment and payment for your treatment. You can read your records, and if you want a copy we can make one for you (but we may charge you for the costs of copying and mailing, if you want it mailed to you). Under limited circumstances, Intuitive Minds Wellness may deny you access to a portion of your records. If you want to access your records, you will need to provide a written record request to the office address above. If you request copies, you may be charged for the reasonable cost of the copy. Intuitive Minds Wellness will also charge you for postage costs, if you request that copies be mailed to you.

The Internet is not a totally secure medium for purposes of transmitting confidential information. Psychiatric advice will not normally be provided via the Internet, and any inquiry or contact with my office via the Internet should NOT be considered a substitute for telephonic, written, secure telehealth or in-person communication. Client realizes and agrees that he/she may be compromising confidentiality if he/she uses such means of communication. Clients with psychiatric inquiries are requested to contact my office by telephone, in writing, or secure messaging. If you are a client, it is discouraged to communicate PHI by e-mail and you are consenting to associated e-mail risks. Again, please note that e-mail is not secure and Intuitive Minds Wellness cannot guarantee that information transmitted will remain confidential. Please do not send personal or confidential information over e-mails. Intuitive Minds Wellness offers a secure, HIPPA-compliant, way for you to view parts of your (child’s) medical records upon request, view normal laboratory results, update personal information and receive clinical summaries. Secure client portals do have certain risks. In order to manage these risks, there are certain conditions of participation.

RXNT client portal is an easy-to use Internet service that provides you quick and secure online access to your clinic health information, scheduling, appointment reminders, and secure online messaging from anywhere at any time.

How to participate in the client portal
The client portal occurs via a website hosted by our electronic health record system. Once you agree to and sign, you will be sent a welcome e-mail, which will give you a username and password to sign in. Because of the security of the website, all information passing between the EHR and your computer is encrypted so that it remains secure. Protecting your private health information and risks.

The security of the client portal requires two things:

• The correct e-mail address and the correct person (or person authorized by that individual)
• Having access to the e-mail.

These two factors are the responsibility of the client. Please notify our office or the client portal any time you change your e-mail address. You must also take care to keep track of who has access to your e-mail account so only you or someone designated by you can view your portal messages.

If you have any concern that someone else has your password, contact our office and we will issue you a new password. We understand the importance of privacy in client care and will continue to strive to make all information as confidential as possible. We will never sell or give away any private information, including your e-mail address.

Additional conditions of participation in the Portal Access
You agree to not hold Intuitive Minds Wellness or any of its staff liable for any network infractions beyond its control. By signing below, you acknowledge that you have read this consent form and that you understand and will comply with it.

I am licensed by the State of Florida and Massachusetts as a Registered Nurse (RN) and Psychiatric Mental Health Nurse Practitioner (PMHNP) with prescriptive authority. Prescriptive authority means I am licensed to prescribe medications within my specialty and scope of practice. I hold a Master of Science in Nursing degree from Columbia University. I am board certified by the American Nurses Credentialing Center as both an Adult and Family Psychiatric Mental Health Nurse Practitioner. In the interest of continuing education, I belong to the American Psychiatric Nurses Association and the Neuroscience Education Institute.