Patient Registration

Full Patient Registration Form

Step 1 of 8

Email Communication Consent

By signing below, I consent to allow Psychiatry of Frederick to use my e-mail address for administrative purposes only.

I understand that this e-mail communication with administrative staff is not to be used for clinical issues, appointment scheduling, prescription requests or billing inquiries.
I understand that this e-mail communication is used for the staff at Psyciatry of Frederick to send and exchange correspondence and forms only.
I understand that if I change my email address it is my responsibility to inform Psychiatry of Frederick.
I understand that all emails will become part of my permanent record.
My consent applies to administrative staff at Psychiatry of Frederick and will continue until I stop this consent in writing.
I understand there are risks in using email to communicate with Psychiatry of Frederick. These risks may include but are not limited to confidential information being seen by others. While Psychiatry of Frederick makes every effort to keep information secure, Psychiatry of Frederick cannot guarantee that electronic communication is 100% safe and protected. You agree that you are entering into electronic communication with full knowledge of the risks therein.
I understand that if I fail to maintain the security of and/or restrict access to my email, and information is seen by others, Psychiatry of Frederick is not in violation of the Health Insurance Portability and Accountability Act (HIPAA).If I fail to maintain the security of and/or restrict access to my email, and information is seen by others, I hereby release Psychiatry of Frederick from all liability.
I understand that Psychiatry of Frederick email is not monitored after business hours.
I understand that I will receive a response within 24 hours during regular business hours, Monday-Thursday 8:30am-2:30pm.

Signature of Patient/Parent/Guardian(Required)

Today's Date(Required)

Financial Agreement

INSURANCES

Please check with our Billing Department to see if we participate with your insurance company. It is your responsibility to verify that we have your current address, phone number and insurance information on file. If we participate with your insurance company, we will submit all services performed in our office for reimbursement unless we have received prior notification of non-covered services. All copays, deductibles, and overdue balances are your responsibility, and payment is expected at the time of each visit. If we do not participate with your insurance company, you are responsible for payment in full at the time services are rendered. We will provide you with a Reimbursement Information Sheet to assist in filing your claim with your insurance company. Insurance companies often require pre-authorization as a condition of reimbursement – whether or not we participate with them. It is your responsibility to obtain any required insurance referrals or authorizations prior to your visit. If a required referral is not presented at the time of your visit, you may be required to reschedule your appointment.

PAYMENT FOR SERVICES

Payment for each visit is expected at the time of service. For your convenience, we accept Visa, MasterCard, Discover, cash, check, or money order. Returned checks will incur a $25 fee to each patient account affected. All patient payments including any outstanding balances are due at the time of service – unless prior arrangements have been made with the Office Manager, Billing Coordinator, and/or your clinician. You will be charged for missed appointments if you fail to provide 24 business hours notice. You are fully responsible for these charges because they are not covered by your insurance. Overdue accounts may incur late fees at 18% per annum. All balances that become 90 days past due may be sent to a professional collection agency. Should your account be sent to a collection agency, you will be financially responsible for a collection fee equal to 33% of the amount sent to the agency and any additional legal fees that our office incurs through the process utilized to collect the outstanding delinquent balance. Your signature below authorizes Psychiatry of Frederick to release information necessary for collection of past due accounts. Payment in full of any past due balance is expected prior to being seen in our office in the future. In addition, payment in full will be expected at the time of service for any future services. INSURANCE AUTHORIZATION AND ASSIGNMENT OF BENEFITS/CONSENT TO TREATMENT I UNDERSTAND THAT CERTAIN INFORMATION MAY BE REQUIRED BY THIRD PARTY SOURCES FOR THE PURPOSE OF TREATMENT, PAYMENT (INCLUDING COLLECTIONS OF PAST DUE ACCOUNTS) AND HEALTH CARE OPERATIONS. I HEREBY CONSENT TO PSYCHIATRY OF FREDERICK RELEASING MY HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS. I HEREBY ASSIGN TO THE PRACTICE ALL BENEFITS/PAYMENTS FOR SERVICES RENDERED TO MY DEPENDENTS AND/OR MYSELF. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL AMOUNTS NOT COVERED BY MY INSURANCE. MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE BEEN PROVIDED PSYCHIATRY OF FREDERICK'S NOTICE OF PRIVACY PRACTICES.

Today's Date(Required)

Signature of Party Financially Responsible/Parent/Guardian(Required)

Informed Consent for Telehealth

This form is designed to allow Informed Consent be given for*(Required)

First Last

Name of Patient

to participate in Telehealth services with(Required)

First Last

Name of Clinician (Therapist or Psychiatrist)

Please read the information below carefully and completely; you are encouraged to ask any questions necessary to ensure your full understanding before providing signed consent for yourself or as the Responsible Party on behalf of the Patient named above.

Clinicians at Blue Ridge represent four professional disciplines whose Maryland State Boards define “Telehealth” similarly but reference it by terms that reflect their specialty: “Teletherapy” when provided by a Licensed Certified Social Worker-Clinical (LCSW-C) or a Licensed Clinical Professional Counselor (LCPC), “Telepsychology” when provided by a Licensed Psychologist (Ph.D./Psy.D, and “Telehealth” when provided by a Maryland Licensed Physician (M.D. Psychiatrist)

For the entirety and purpose of this Consent form, the term “Telehealth” is used for all Clinicians at BRBH, regardless of their discipline, except where noted, and is defined as follows: the use of interactive audio, video, audio-visual, or other telecommunications or electronic technology that allows the Clinician to provide mental health services within one’s scope of practice to a Patient who is at a different physical location.

Telehealth does not include communication between a Clinician and Patient by means of telephone calls, e-mails, fax, or text message. However, during certain Federal and/or State of Emergencies, an Executive Order(s) may permit, for a limited time, Telehealth services be provided by audio-only interactions (i.e., by telephone); the Clinician will inform a Patient when and under what conditions this is allowed.

This Consent is specific to Telehealth services. It does not replace but is used in conjunction with the Informed Consent document (“BRBHS Patient’s Rights and Responsibilities Form”) required to be signed by all Patients prior to the start of mental health evaluation/treatment at Blue Ridge Behavioral Health (BRBH/Blue Ridge).

Clinicians at Blue Ridge will provide Telehealth services by conducting online sessions using Doxy.me, a HIPAA compliant videoconferencing software platform that meets the standards of encryption and privacy protection. It also provides a Business Associate Agreement for the Clinician to sign. There is no fee for Patients to use Doxy.me, and instructions will be given for how to use the service before connecting for online sessions.

Telehealth provides a way for a Clinician to deliver mental health services when circumstances such as time, travel restrictions, or health impairments, for example, prevent these services from occurring at the Clinician’s office. However, it’s important to understand fully the rights, risks, limitations, and responsibilities stated below for the Patient and/or Clinician when using Telehealth.

Clinicians must provide Telehealth in compliance with State laws and regulations, including those regarding the locations of the Clinician and Patient during the Telehealth session. The Patient agrees to be honest about his/her/their location and emergency contact information the Clinician may request. Failure to do so may result in the termination of the use of Telehealth and/or the end of the Patient-Clinician relationship. Should this occur, the Clinician will discuss the plans for transfer of the Patient’s mental health care, which will include providing referral sources.
When Telehealth uses videoconferencing for the delivery of services, a Patient will be participating in virtual “face to face” treatment sessions rather than in-person “face-to-face” sessions at the Clinician’s office. The Patient understands he/she/they may experience sessions somewhat differently and accepts that the quality of transmitted information may affect the quality of services provided.
Telehealth comes with limitations specific to Psychiatrists that may impact the quality of care a Psychiatrist can provide. The Psychiatrist cannot monitor a Patient’s vital signs, including blood pressure, height, and weight. The Psychiatrist may not be able to order or obtain laboratory studies (for example, blood work, urinalysis, EEG, or EKG) that provide information necessary for Patient care. The Patient understands that if the Psychiatrist does not have information about the Patient’s vital signs and/or required laboratory studies, it could limit the decisions the Psychiatrist can make regarding management of prescribed medications. This includes decisions about starting medication, changes in medication(s) currently prescribed, and/or the dosing of these medications.
The Patient is responsible for providing his/her/their own equipment that will allow the Patient to connect with the Clinician for Telehealth sessions. This includes a computer, smartphone, or tablet, a webcam either built into a device or added to it, and non-public Internet access to conduct the sessions. The Clinician and Patient each have the responsibility to ensure the security of one’s own equipment and of the internet access at one’s own location.
The Patient understands that Telehealth, when provided online, is technical in nature and that problems may occur due to problems with internet connections or interruptions related to any equipment or software being used and/or services provided by a 3rd party. The Clinician has no control over any of these situations, nor guarantees that any services will work as expected.
If something occurs to prevent or disrupt any scheduled appointment due to technical complications, and the session cannot be completed via online videoconferencing, the Patient agrees to contact the Clinician to reschedule.
The Patient understands there are no guarantees for privacy protection when any information is transmitted by the internet. The Clinician will inform a Patient if Doxy.me provides notification that a data breech occurred.
The Patient understands there is a risk of being overheard by anyone nearby if the Patient is not in a private room while participating in Telehealth. It is the Patient’s responsibility to arrange a location with sufficient lighting and privacy, free from distractions or interruptions, for one’s Telehealth sessions. It is the Clinician’s responsibility to do the same in the environment in which sessions are conducted.
The Patient agrees to inform the Clinician of other persons knowingly present in the location for the Telehealth session. The Patient understands the Clinician may ask others to leave the location or may end the Telehealth session if there is concern that confidential information will be compromised or the presence of the person(s) interferes with the productivity of the online session.
The Patient understands and agrees that there will be no recording of any of the online sessions by either the Clinician or the Patient. It is also understood that all information disclosed within sessions and the written records pertaining to those sessions are confidential and may not be revealed to anyone without the Patient’s written permission, except where disclosure is required by law.
The Patient has the right to access the written records of the Patient’s Telehealth sessions in accordance with the same laws that permit the Patient to access written records of any in-person sessions with the Clinician.
The Patient accepts that Telehealth does not provide emergency services and can limit the ability for the Clinician to fully evaluate and determine if the Patient requires emergency care. The Patient understands that when experiencing a mental health emergency, the Patient can call 9-1-1 or proceed to the nearest hospital emergency room if able to do so safely. Patients who are actively at risk of harm to self or others are not suitable for Telehealth services. If this is the case or becomes the case in the future, the Clinician will recommend more appropriate services.
The Patient understands that he/she/they will be treated with the same standard of care that would be provided if treated in person. It is also understood that results of Telehealth cannot be guaranteed nor assured. There are risks and benefits associated with any form of mental health services and despite the efforts of the Patient and the Clinician, the Patient’s condition may not improve and in some cases, may even worsen.
The Clinician may determine that Telehealth sessions are not in the Patient’s best interest and will discuss other forms of mental health services better suited to the Patient’s needs.
The Patient understands the right to withhold or withdraw consent to participate in Telehealth services at any time without affecting the right to future care or treatment.
The Patient has the responsibility to keep any scheduled telehealth appointments and will be charged for missed appointments or cancellations for which 24-hour’s notice, not to include weekends/holidays, has not been given.

In signing this Consent form, I acknowledge that I have read and understand all the terms and information provided herein. I was given ample opportunity to ask questions or seek clarification for anything I did not understand or that was unclear to me. I understand I will be responsible for payment of Telehealth services that are not covered by the Patient’s Insurance Provider. I voluntarily consent for the Patient to participate in Telehealth for mental health evaluation/treatment services.

I understand that due to problems that may occur with internet connections for the Patient and/or Clinician, it may be difficult to connect/reconnect for scheduled Telehealth sessions. Therefore, I authorize use of the following email address and cell phone number as options for the Clinician when arranging the sessions. I also agree to contact the Clinician to reschedule if a session could not be completed.

Signature of Patient or Responsible Party if not Patient*(Required)

Today's Date(Required)

Patients Rights & Responsibilities

Patients have the right: 1. To be treated humanely, with dignity, and respect. 2. To not be discriminated against due to race, religion, ethnicity, gender, sexual orientation, or disability. 3. To receive treatment appropriate to their mental health condition. 4. To have diagnosis and treatment explained in understandable terms. 5. To participate in the formulation and revision of the treatment plan. 6. To refuse treatment, request another provider, or seek a referral outside of the practice. 7. To receive services that adhere to the principles of confidentiality and privacy except for the following specialized circumstances: a. When circumstances place the patient’s welfare or that of others in immediate danger. b. When disclosures made by the patient raises the suspicion of child physical, mental, or sexual abuse or neglect, or if an adult discloses an allegation of abuse in their childhood. In this situation, the law requires a report be made to the appropriate agency, usually Social Services. c. When a court order requires testimony or release of patient’s records. d. In a circumstance where the provider determines that consultation within the practice is needed in order to provide optimal treatment, in which case the utmost discretion will be used to insure privacy. 8. To access your medical record as deemed appropriate by the provider. Patients have the responsibility: 1. To know the benefits and exclusions of your insurance coverage and to provide us with current insurance information. 2. To make regular and prompt payments for services rendered. 3. To keep scheduled appointments. Patients will be charged for missed appointments or cancellations for which 24 hour notice has not been given. 4. To follow the mutually agreed upon treatment plan. 5. To be open and honest in sessions. 6. To report any safety concerns or abuse allegations to your provider. 7. To discuss with your provider any concerns about treatment, including the desire to terminate treatment. 8. To discuss with your provider any concerns about treatment, including the desire to terminate treatment.
Office Hours Evening, weekend and other hours are available at the discretion of your clinician. The business office is open Monday through Friday from 8:30am until 4:30pm. Appointments All appointments are scheduled. Psychiatrist’s appointments are scheduled by the administrative staff. All other appointments are scheduled by your clinician. Twenty-four hours notice is required to cancel an appointment. Payment for missed appointments are the responsibility of the patient. Missed appointment charges are as follows: Psychiatrist = $180; Psychologist = $175; Counselors or Social Workers = $160. Telephone Service The office uses a voice mail system. Please listen carefully to all options. During business hours, you can direct your call to the receptionist at any time by selecting “0”. If you know the extension of your clinician, you may enter it at any time. If you do not know your clinician’s extension, you can press “4” for a directory. The prescription line is monitored daily until 4:00 p.m. The following services can be reached directly by entering the appropriate extensions: New patients – 1 Prescription refills – 2 Physician scheduling – 3 Billing – 5 Emergencies If you have an emergency outside of normal business hours, contact our answering service at 301-712-9183. If your clinician is unavailable, the answering service will direct you to the on-call clinician. Please do not call for non-emergency problems after regular business hours. Prescription Refills There are 2 ways to request prescriptions. 1. Website request form- Under the prescription request tab (www.psychiatryoffrederick.com) 2. Leave a message on the prescription voicemail- Ext. 112 or option 2 (301-695-8390) ALLOW A MINIMUM OF 48 HOURS FOR PRESCRIPTIONS TO BE PROCESSED. Managed Care Managed care plans have various rules about how to begin treatment. If your plan requires a referral from your primary care physician, we must receive the referral prior to the first visit. Some plans require phone authorization before beginning treatment. If the required referral or authorization is not presented at the first visit, you agree to waive your insurance benefits and you will be responsible for payment in full at time of service. Other Fees Psychiatrists charge $300 per hour, rounded to the nearest 15-minute interval, for school or team conferences, consultations conducted by telephone, and time spent reviewing, preparing, and/or writing reports. The charge for court-related services is $600 per hour rounded to the nearest 15-minute interval. Psychologists charge $175 per hour, rounded to the nearest 15-minute interval, for school or team conferences, consultations conducted by telephone, and time spent reviewing, preparing, and/or writing reports. The charge for court-related services is $360 per hour rounded to the nearest 15-minute interval. Social Workers charge $160 per hour, rounded to the nearest 15-minute interval, for school or team conferences, consultations conducted by telephone, and time spent reviewing, preparing, and/or writing reports. The charge for court-related services is $300 per hour rounded to the nearest 15-minute interval. The minimum charge for copies of patient records is $15 plus 50 cents per page. The maximum copying charge per patient chart is $75. There is an additional fee of $15 if the chart is archived off-site (typically older than 2 years). These charges are not subject to insurance reimbursement and are the responsibility of the patient. CRISP NOTICE We have chosen to participate in the Chesapeake Regional Information System for our Patients (“CRISP”), a regional health information exchange (“HIEs”) serving Maryland. CRISP is also affiliated with and shares data with other HIEs, including those, in Alaska, Connecticut, D.C., Maryland, and West Virginia. As permitted by law, your health information will be shared with this exchange in order to provide faster access, better coordination of care and assist providers and public health officials in making more informed decisions. You may “opt-out” and disable access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt Out form to CRISP by mail, fax or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (“PDMP”), will still be available to providers

Signature of Patient / Guardian(Required)

Today's Date(Required)

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Please complete patient forms online before your first appointment.

Patient Registration

Full Patient Registration Form

Insurance Information

Intake Request Form

Billing Authorization Form

Email Communication Consent

Financial Agreement

INSURANCES

PAYMENT FOR SERVICES

Informed Consent for Telehealth

Notice of Fees

Patients Rights & Responsibilities

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