MW Psychiatry I Jia Wang MD

New Visit Packet


NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND SAFEGUARDED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

I. Who is Subject to This Notice
MW Psychiatry, PLLC

II. Our Responsibility
The confidentiality of your personal health information is very important to this practice (MW Psychiatry). Your health information includes records that were created and obtained when the practice provides you care, such as a record of your symptoms, examination and test results, diagnoses, treatments and referrals for further care. It also includes bills, insurance claims, or other payment information that are maintained related to your care.

This Notice describes how MW Psychiatry handles your health information and your rights regarding this information. We are required to:
- Maintain the privacy of your health information as required by law;
- Provide you with this Notice of the office duties and privacy practices regarding your collected and maintained health information;
- Follow the terms of this Notice currently in effect.

III. Contact Information

After reviewing this Notice, if you need further information or want to contact MW Psychiatry for any reason regarding the handling of your health information, please direct any communications to the following contact person:
Jia Wang, MD

IV. Uses and Disclosures of Information
Under federal law, the providers at MW Psychiatry are permitted to use and disclose personal health information without authorization for treatment, payment, and health care operations. However, the American Psychiatric Association’s Principles of Medical Ethics or state law may require us to obtain your expressed consent before the practice makes certain disclosures of your personal health information. Participants of MW Psychiatry may share health information with each other, as necessary to carry out treatment, payment, or health care operations relating to the practice.

V. Other Uses and Disclosures
In addition to uses and disclosures related to treatment, payment, and health care operations, this practice may also use and disclose your personal information without authorization for the following additional purposes:

Abuse, Neglect, or Domestic Violence
- As required or permitted by law, MW Psychiatry may disclose health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, the providers will use their professional judgment in deciding whether or not to make such a report. If feasible, we will inform you promptly if such disclosure has been made.

Business Associates
- MW Psychiatry may share health information about you with business associates who are performing services on our behalf. For example, the practice may contract with a company to service and maintain computer systems, processing billing, payments, and collecting outstanding fees, etc. MW Psychiatry’s business associates are obligated to safeguard your health information. MW Psychiatry will share with our business associates only the minimum amount of your personal health information necessary for them to assist the practice.

Communications with Family and Friends
- MW Psychiatry may disclose information about you to persons who are involved in your care or payment for your care, such as family members, relatives, or close personal friends. Any such disclosure will be limited to information directly related to the person’s involvement in your care.
- If you are available, we will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, we will use our best professional judgment to determine what is in your best interest regarding any such disclosure.

Food and Drug Administration (FDA)
- MW Psychiatry may disclose health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug or medical device.

Health Oversight
- MW Psychiatry may disclose health information about you for oversight activities authorized by law or to an authorized health oversight agency to facilitate auditing, inspection, or investigation related to our provision of health care, or to the health care system. This includes possibly your insurance company/companies, Medicare/Medicaid, and/or pharmacies that require certain health care information in order process claims or medication approval.

Law Enforcement
- MW Psychiatry may disclose health information about you to a law enforcement official for certain law enforcement purposes. Such disclosure will only occur when required by law.
Judicial or Administrative Proceedings
- MW Psychiatry may disclose health information about you in the course of a judicial or administrative proceeding, in accordance with our legal obligations.

Minors
- If you are an unemancipated minor under Texas law, there may be circumstances in which MW Psychiatry disclose health information about you to a parent, guardian, or other person acting in loco parentis, in accordance with our legal and ethical responsibilities.

Notification
- MW Psychiatry may notify a family member, your personal representative, or other person responsible for your care, of your location, general condition, or death.
- If you are available, MW Psychiatry will provide you an opportunity to object before disclosing any such information. If you are unavailable because, for example, you are incapacitated or because of some other emergency circumstance, we will use our professional judgment to determine what is in your best interest regarding any such disclosure.

Parents
- If you are a parent of an unemancipated minor, and are acting as the minor’s personal representative, MW Psychiatry may disclose health information about your child to you under certain circumstances. For example, if we are legally required to obtain your consent as your child’s personal representative for your child to receive care from here, we may disclose health information about your child to you.
- In some circumstances, MW Psychiatry may not disclose health information about an unemancipated minor to you. For example, if your child is legally authorized to consent to treatment (without separate consent from you), consents to such treatment, and does not request that you be treated as his or her personal representative, we may not disclose health information about your child to you without your child’s written authorization.

Personal Representative
- If you are an adult or emancipated minor, MW Psychiatry may disclose health information about you to a personal representative authorized to act on your behalf in making decisions about your health care.

Public Health Activities
- As required or permitted by law, MW Psychiatry may disclose health information about you to a public health authority, for example, to report disease, injury, or vital events such as death.

Public Safety
- Consistent with MW Psychiatry’s legal and ethical obligations, we may disclose health information about you based on a good faith determination that such disclosure is necessary to prevent a serious and imminent threat to the public.

Required By Law
- MW Psychiatry may disclose health information about you as required by federal, state, or other applicable law.

Research
- MW Psychiatry may disclose health information about you for research purposes in accordance with our legal obligations. For example, we may disclose health information without a written authorization if an Institutional Review Board (IRB) or authorized privacy board has reviewed the research project and determined that the information is necessary for the research and will be adequately safeguarded.

Specialized Government Functions
- MW Psychiatry may disclose health information about you for certain specialized government functions, as authorized by law. Among these functions are the following: military command; determination of veterans’ benefits; national security and intelligence activities; protection of the President and other officials; and the health, safety, and security of correctional institutions.

Workers’ Compensation
- MW Psychiatry may disclose health information about you for purposes related to workers’ compensation, as required and authorized by law.

VI. Your Health Information Rights
Under the law, you have certain rights regarding the health information that MW Psychiatry collects and maintains about you. This includes the right to:
- Request the practice to restrict certain uses and disclosures of your health information; MW Psychiatry is not, however, required to agree to a requested restriction.
- Request the practice to communicate with you by alternative means, such as making records available for pick-up, or mailing them to you at an alternative address, such as a P.O. Box. MW Psychiatry will accommodate reasonable requests for such confidential communications.
- Request to review, or to receive a copy of, your health information that is maintained in MW Psychiatry’s files and the files of our business associates (if applicable). If MW Psychiatry is unable to satisfy your request, we will tell you in writing the reason for the denial and your right, if any, to request a review of the decision.

VII. Effective Date:
July 1, 2014

Initial Here: *required


OFFICE FEES AND POLICIES

This document contains information about professional services and business policies.  Please read it carefully and feel free to bring up any questions you have.  When you sign this document, it represents an agreement between you and MW Psychiatry, PLLC (the practice).

MW Psychiatry is currently an in-network provider for select insurance companies.  A service receipt with the required appointment information and diagnostic codes is available for each visit.  If you are paying with insurance, this is submitted to your insurance on your behalf.  If you are self-paying, you may submit it to your insurance for out-of-network benefits or to a medical spending account for reimbursement.

Coaching/supervision is not a medical service. No medications will be prescribed, no diagnosis will be given, and no service code will be available.  It is not covered by health insurance and will be self-pay only.

Professional Fees:

Payment is due at the time services are rendered.  Below are the fees for self-pay patients/clients.  If you are using insurance, you will be responsible for your share of the fees per contracted with the insurance company at the time of service.  Please call our billing department for your insurance details.  If your insurance is/becomes out-of-network, you will be responsible for the visit at the self-pay rate below.  If an in-network insurance claim is denied, any outstanding fees will be invoiced to you (the patient) at the contracted rate.  Once you have self-paid for a visit, we do not retroactively submit that visit to insurance.  Please alert us ahead of a visit if you are changing your method of payment.  No refunds are given after a service has been rendered or per appointment policy below.

We accept cash, cashier’s checks, Zelle Quickpay, and card payments.  Outstanding fees, back charges from card services/banks, cancelled checks will be added to your account and invoiced to you.  The outstanding balance on your account (copays, late charges, unpaid claims, etc.) is sent to a collections agency annually.  We do not wish this to happen, so please contact Dr. Wang if you need a payment plan.

Fees will be reassessed periodically and increases may occur.

Initial Evaluation (up to 40 minutes)  $350

Follow up appointment (20 minutes)  $170

Follow up appointment (40 minutes, self-pay only)  $280

Telephone Therapy (each 10 minutes, cannot replace a regular follow-up, self-pay only)  $85

Legal Fees (per hour, plus travel time and expenses, self-pay only)  $800

Coaching/Supervision (20 minutes, self-pay only)   $170

Coaching/Supervision (40 minutes, self-pay only)   $280

Appointment Policy:

  • No-Show Appointment: Each no-show appointment is charged according to the service at the self-pay rate. Leaving before being seen is considered no-show. Insurance does not reimburse no-show appointments.
  • Cancellations/Reschedules: Cancellations/reschedules made 2 days in advance of the scheduled appointment are not charged. Late cancellations/reschedules are charged according to the service at the self-pay rate.  Insurance does not reimburse late cancellations/reschedules.
  • Make-up Appointment: The no-show or late cancel/reschedule fee can be refunded in full for a 20 min appointment or at 50% for a 40 min appointment upon attendance of a make-up session within one week of the missed appointment. If the make-up session is dated outside the one week grace period, or if it is cancelled, no-showed, or rescheduled, then you will forfeit the refund.  For repeated no-shows or late cancel/reschedules, we reserve the right to charge.
  • Late Arrivals: We do not extend appointment times out of respect to your time and the subsequent person's time. If you are late, you can use the remainder of your time, wait until the next available opening, or reschedule. If we are late, we will make up the time with you.
  • Outstanding balance/missing paperwork/no payment: Anyone with an outstanding balance, missing active card on file, missing paperwork, or do not have their payment at the time of service will be marked as late-cancel and asked to reschedule with balance to zero and proper paperwork/payment filed. No medications will be prescribed until any outstanding charges are paid in full, and we have a complete file with proper paperwork completed.
  • Any patient/client under 18 years old who arrives without a parent or guardian will be asked to reschedule. We ask that adult patient/clients do not bring their children to the appointment due to adult nature of the work.

Medication Policy:

  • To uphold the highest standard of care, all medication adjustments and refills are done during your appointment. We will provide you with enough medication to last to the next recommended follow-up.  This practice does not refill or adjust medications by phone, fax, or email due to safety concerns.
  • Any urgent refills of non-controlled medications outside of the appointment incurs a fee of $25 up to a 2-week supply per medication and are done on a limited basis.
  • Controlled medications are monitored carefully and are only refilled during appointments. Sharing, distributing, or alterations of the prescription are in violation of the law.  We cannot prescribe controlled medications to anyone that we cannot see in person.  Please see TREATMENT AGREEMENT for detailed policy regarding controlled medications.

Miscellaneous Policy:

  • This practice processes all paperwork and record requests (except prior authorizations) during your appointment time. Forms for us to complete outside of your appointment is charged by complexity/time: $25 per document that takes less than 5 minutes or $75 for each ten minutes. Record requests are $25. Notary, travel, or packaged mail charges are additional.
  • Disability assessments and FMLA recommendations are only performed if the provider and the applicant have an on-going treatment relationship. This is the only way to ensure an accurate picture of a person’s function.  We retain the right to decline a disability assessment.  Please see TREATMENT AGREEMENT for detailed medical leave and disability policy.
  • This office does not provide translation services. You must have your own licensed language interpreter if you speak a language other than English or Mandarin Chinese.
  • Office visits, calls, texts, emails and any other form of communication may be added to your medical records as part of your record.
  • Florida telehealth patients must have access to in-person healthcare outside of our work. This includes access to labs, procedures, imaging, and emergencies. We highly recommend for all Florida patients to have an in-person primary care provider.

Telephone Contact Policy:

  • Calls regarding appointments, updates, questions, or clarifications are entirely appropriate and encouraged (no charge).
  • Calls of a therapeutic nature (and/or non-routine matters) will be charged by increments of 10 minutes; this is a service for in-between sessions; it does NOT replace regular follow-up sessions.
  • Calls initiated by your family member or provider that involves case discussion will require a signed release of information by you; time used to relay the information is charged to your account by increments of 10 minutes.
  • All routine voicemails will be returned during business hours. Calls without voicemails will not be returned. For urgent matters after hours, state that it is urgent in your voicemail and we will get back with you as soon as we can.

Text/Email Contact Policy:

  • This practice does not use texting as a primary form of discussion of on-going matters. This reflects our concerns about confidentiality and maintaining an optimal standard of care. Please bring most topics to the appointment.
  • This practice appreciates that text can be a time-efficient means of communicating short requests, such as appointments or medication clarifications, and this may be used. Please understand that text is NOT a confidential form of communication and the content of text messages is not protected. Alert us if you do NOT wish to be texted.
  • This practice welcomes e-mails for non-urgent administrative communication. Please note that the confidentiality of your e-mail cannot be guaranteed. E-mail is only checked on business days and often only once per day; it is not appropriate for urgent communications. 

Signing below you (the patient) acknowledge your agreement with MW Psychiatry’s Office Fees and Policies and to accept personal responsibility for ensuring that all charges for services rendered and/or per office policy will be paid in full.  You agree that filing for out-of-network insurance reimbursement is your responsibility should you choose to do so.

Initial Here: *required


TREATMENT AGREEMENT

  1. Notify us of all current psychiatric and medical conditions, all current medications, and how you are taking them.
  2. Notify us if you suspect or know that you are pregnant or if you plan to become pregnant in the near future. Pregnancy will affect treatment recommendations.
  3. If you need immediate medical attention due to safety concerns, call 911 or proceed to your nearest emergency room.
  4. If your medication makes you drowsy or slows your reaction time, refrain from operating any motor vehicle, machinery or equipment, and notify us so that we can discuss it at our next appointment.
  5. If you have severe, intolerable side effects, you may stop your medication and notify us. Most mild side effects are temporary and can be discussed at your next visit.
  6. Please avoid making medication changes without discussing it first with us at your appointment. Medication management is a collaborative process. Changes without consultation are potentially dangerous and may interfere with our ability to work together.
  7. If you are taking a controlled medication: These medications are strictly regulated; sharing, distributing, or alterations to the prescription are in violation of the law. No prescription is issued outside of an appointment.
  • You must take it according to the provider’s instructions. This office does NOT issue early refills unless it has been discussed with us ahead of time.
  • This practice does not replace lost prescriptions.
  • If you need a replacement (for expired or damaged prescription), you must make an appointment and return the damaged prescription (if applicable). Stolen prescriptions must be accompanied by a police report.
  • Electronically sent medications are NOT transferrable to different pharmacies. (We will not be sending it to a different pharmacy. If your pharmacy is out of stock, contact us.)
  • If you miss your appointment, you will not get refills. You must follow up.
  • If this practice learns that you are receiving similar medications from different providers, misusing your medications, sharing your medications, or taking medications from non-prescribers, you will no longer be able to receive any controlled medications from this clinic.
  • If you have altered dose/amount on the prescription, you will be immediately discharged from this practice.
  • For your safety, you must disclose all current controlled medications and how you are taking them. Failure to do so will interfere with our ability to work together and may result in being discharged from this practice.
  • You may be asked to complete unannounced urine drug screenings. If you choose to refuse a urine drug screen on the day that it is ordered, you may lose the ability to further obtain controlled medications from us or even be discharged from the practice.
  1. We advise all patients to refrain from using alcohol, tobacco, cannabis, and other illicit drugs while undergoing psychiatric treatment.
  2. Please notify us as soon as possible if you have a change to any of your demographic information or insurance.
  3. All forms, such as school, insurance, disability, FMLA, except for prior authorizations, are done during your appointment. If you require this practice to complete a form outside of your appointment time, it is charged by document or by time, depending on the complexity.
  4. Disability and Medical Leave Policy:
  • We reserve the right to decline a disability assessment for any reason.
  • Disability or need to take medical leave is determined by your providers. You may or may not agree with our assessment. We will not be changing any elements of the disability application or work form based your opinions.
  • If we do not feel that that we have adequate information to depict your function, we will let you know.
  • Recommendations for medical leave are made carefully. If we recommend for you to take medical leave for a higher level of treatment and you decline, this will interfere with our ability to work together.
  • The treatment goal is to improve and to restore function, not to prolong disability. If you are not taking medications as prescribed, only wanting to take certain medication(s), not reporting worsening symptoms for prompt treatment, not following treatment recommendations, or not following-up with us as recommended, we will be reporting it to your disability and/or medical leave office. In addition, this hinders our ability to work together and you might be discharged from the office.
  • We will be doing random unannounced urine drug screening. Lack of cooperation will be counted as non-compliance, it will be reported to the disability and/or medical leave office, and you will be discharged from this office.
  • We will not complete any forms in or out of the office if you have any outstanding balance on your account.
  1. This office may discharge a patient/client. Here are some (but not all) of the reasons for doing so:
  • Inability to establish rapport.
  • The service requested is outside the scope of our practice.
  • The diagnoses or conditions reported are outside the scope of our practice.
  • Patient has moved out of state.
  • Patient’s insurance has termed or is out of network and has elected not to self-pay.
  • Non-compliance with treatment recommendations.
  • Non-compliance with office policies.
  • Misuse or unlawful use of prescriptions.
  • Consistently missing appointments.
  • Threats, name-calling, and use of intimidation to providers or office staff.
  • Persistently seeking/demanding a specific medication or a class of medication, when the provider does not think it is appropriate.
  • And others.

Coaching and Supervision: Coaching or supervision is a non-medical service. Thus, we will not be able to complete any medical related forms or perform any medical assessments during the session. If we determine that you are best served under psychiatric care, we can recommend a psychiatric assessment or provide you with a referral. We will also help you with a referral if we think you need any other additional services.

I have read and agree to the preceding TREATMENT AGREEMENT. 

Initial Here: *required


INFORMATION REGARDING PAYMENT

We require every patient/client to have an active card with sufficient funds on file and linked to your secure profile at Square.com to obtain treatment at this office.  Please note, we are ONLY able to accept a bank related debit or credit card to be placed on file.  (We do not accept reloadable cards or health account cards.)

This card is used primarily for late cancellations and no-show appointments, telemedicine appointments, and occasionally for outstanding charges due to extraordinary circumstances (this is very rare and we will contact you prior to charging your card).  If you choose, this card can be used to pay for your portion of the office visit. 

Accepted payment methods include cash, Zelle Quickpay, cashier’s check, and credit/debit card (Visa, MasterCard, American Express, Discover).

Please alert us if your card ever becomes inactive.  An alternate card needs to be placed on file.

If you do not wish to have a card on file, you are required to keep a retainer of $500.  We will keep this money in your account and deduct from it with each of your visit.  When it reaches below $100, you will have to renew it to $500.  In the event that you wish to transfer care to another provider, we will refund your remaining balance.

I authorize MW Psychiatry to charge my credit/debit card AND any card used/saved at Square.com:

Card Holder's Name: *required

Card Number: *required

Exp Date: *required

CVV/CVC: *required

Card Billing Zip Code: *required

By signing below, I understand that I will be charged for any outstanding fees on my account as per OFFICE FEES AND POLICIES using this card OR any card I used/saved at Square.com.  I am aware that I will be responsible for any outstanding charges not reimbursed by insurance.  I am aware that insurance will not reimburse charges for missed appointments.  I am aware that back charges from card services and cancelled checks will also be added to my account and I will be charged.  I am aware and agree that a test transaction of $1 may be charged to my card to verify that it is a valid card, and this will be refunded to me.  I am aware that outstanding charges on my account may be sent to a collections agency.

Initial Here: *required


Please upload patient/client's (or responsible party's) ID (*required): 

If you are using insurance, please also upload a copy of your insurance card (front and back) (*required if using insurance): 


Patient/Client's Name: *required

Signer's Name: *required

Relationship to Patient/Client (if not self):

December 2, 2020

Leave this empty:

Signature arrow
MW Psychiatry I Jia Wang MD https://www.jiawangmd.com
Signature Certificate
Document name: New Visit Packet
lock iconUnique Document ID: 9a0893d4cb17eeb95d1b91d56eda86e50f89df26
Timestamp Audit
July 6, 2020 11:53 pm CSTNew Visit Packet Uploaded by Jia Wang MD - contact@jiawangmd.com IP 73.136.78.98
July 8, 2020 6:43 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
July 8, 2020 6:50 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
July 8, 2020 10:42 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 98.201.161.10
July 8, 2020 10:47 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 98.201.161.10
July 8, 2020 10:49 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 98.201.161.10
July 8, 2020 10:54 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 98.201.161.10
July 8, 2020 11:08 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 98.201.161.10
July 9, 2020 12:11 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
July 10, 2020 4:45 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
July 11, 2020 12:51 am CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 98.201.161.10
July 15, 2020 12:23 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
July 20, 2020 12:49 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
July 31, 2020 5:24 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
September 28, 2020 3:38 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
September 28, 2020 3:55 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98
December 1, 2020 12:57 pm CSTTim Wang - jqwang@jiawangmd.com added by Jia Wang MD - contact@jiawangmd.com as a CC'd Recipient Ip: 73.136.78.98