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 NoticeMW Psychiatry, PLLC
II. Our ResponsibilityThe 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 InformationUnder 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 DisclosuresIn 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 RightsUnder 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.
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
Telephone Contact Policy:
Text/Email Contact Policy:
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.
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.
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
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.
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):
September 19, 2020
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: New Visit Packet
Agree & Sign