Below is a summary of policies and patient agreement, please see links on sidebar for policy specifics prior to initial contact. Contact with Mountain Psychiatric LLC implies acknowledged access to and knowledge of policy specifics on this website.
I (as patient) understand that participating in treatment with Mountain Psychiatric LLC is an investment of time, effort, and money. Compliance with medical advice is imperative for treatment success. This includes arrival and participation in agreed upon treatment sessions, proper self-management of prescribed medications including secure storage and timely refill requests, disclosure of adverse effects, comorbid medical problems or symptom changes, and timely management of account.
I understand that I am financially responsible for services rendered and that my account is due in full each session. I understand that Mountain Psychiatrics LLC does not accept assignments of benefits from insurance carriers. I also understand that late charges of 50% will accrue on any unpaid portion of my account and that there is a $40.00 service charge for any returned checks. Accounts past due without arrangements for payment will be sent to collections.
I understand it is my responsibility to secure authorization from my insurance company, PPO, or Managed Health Care Company before any office visits occur. I agree to pay each visit in full and file my own insurance or allow the office to file on my behalf, under certain circumstances.
I understand and accept the confidentiality policy found on the business’ website. I also understand that Mountain Psychiatric LLC must release minimally necessary Protected Health Information to insurance companies should they request it (with the consent of the patient). Psychotherapy notes are not released.
I agree that the doctor’s role is limited to providing treatment and that I will not involve him or her in any legal dispute. I am waiving rights to access specific treatment notes but understand that a treatment summary can be furnished at any time with adequate notice.
I understand that during the course of treatment it may become necessary to increase fees to compensate for increased costs and inflation. Fees will be reviewed periodically and will be increased no more than once during any calendar year.
I understand that I may terminate treatment at any time with no cause and that a good-faith effort will be made by Mountain Psychiatric LLC to provide a 30-day supply of current medications and referral if needed. I also understand that Mountain Psychiatric LLC may terminate treatment for bad-faith breach of trust, un-remedied non-compliance, and non-payment of bills.
I have read the Business Policies and Patient Agreement, understand, and accept the policies described above and on this business’ website www.mountainpsychiatric.com prior to initial contact with Mountain Psychiatric LLC and will clarify any policy questions prior to initiation of treatment.