Informed Consent

 

We are glad you chose Old Towne Counseling Services, LLC to provide your behavioral health services. We care about our clients and the services we provide. In order to ensure that we are able to provide services to many we are now requiring that your paperwork is completed within 24 hours from scheduling the appointment. The completion and submission of this paperwork confirms your appointment. **If you do not attend this appointment there will be a missed appointment fee as noted below.

 

PLEASE READ: Please ensure that you are able to attend the INTAKE APPOINTMENT scheduled. If you need to cancel this appointment please cancel or reschedule with 24 hours notice in order to not incur a fee.

 

The fees for not attending an intake appointment are: $80.00  for a Therapist Appointment, $140 for a Psychiatric Nurse Practitioner Appointment, $500 for a Psychological Evaluation Appointment, or $100 for an Appointment with a Psychologist, $60 for an appointment with a provisionally licensed provider. Additionally these cancellation fees apply to all future appointments that are not attended or cancelled within 24 hours of the scheduled appointment.

Please read the following important information carefully and sign in agreement regarding terms of services received at Old Towne Counseling.

Participation in Treatment:

• Each client has the right to participate in decisions regarding their behavioral health care, including the right to refuse treatment. Providers shall ask the individual to express their preferences about decisions regarding all aspects of services that affect them and shall honor these preferences to the extent possible. If you have any questions regarding this consent form or about the services offered at Old Towne Counseling Services, LLC, you may discuss them with your provider. You understand that you may stop treatment at any time.

• If at any time your provider becomes aware of a conflict of interest, or extenuating circumstance that deem it necessary to terminate services, a referral will be made and your provider will offer assistance in assuring continuity of care.

 

Scope of Services Provided: 

• Services provided by Old Towne Counseling are not crisis, emergency, or acute in nature and should not be utilized as such. In the case of a medical or mental health emergency, clients agree to call 911 or utilize the local crisis services offered by the community mental health board. Correspondence via text, phone call, or email should not be utilized in emergency or crisis circumstances.

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Confidentiality: 

• All services and information disclosed therein are confidential and protected under the Health Insurance Portability and Accountability Act (HIPAA) with the exceptions of disclosures required by law and when deemed necessary to provide the best care.

• Providers may consult with professional colleagues when clinically advisable. Providers within Old Towne Counseling will work collaboratively when a client is receiving services from multiple providers, for example when a client is seeing both a nurse practitioner and a therapist.

• The client understands that protected health information will be released in compliance with regulations and for any information necessary to process insurance claims including, without limitation, preauthorization for medications.  

• All disclosures, regardless of circumstances, will be limited to only pertinent or relevant information to meet the purpose of the disclosure.

 

Appointments: 

• We offer an appointment reminder service. Please let us know which number or email address you would like the notification to be sent to. Please do not rely solely on this service. 

• It is the client’s responsibility to attend sessions on time. Please arrive 10 minutes early for all scheduled appointments. For telehealth sessions please allow 5-10 minutes before your scheduled session time for any potential technical issues to avoid delays in starting your appointment on time.

• Providers will allow a grace period of 10 minutes for medication management appointments or 15 minutes for therapy or evaluation appointments, after which time your appointment will be considered a missed appointment and related fees will apply. 

• Your consistent presence is needed for us to effectively do our work. Please make every effort to attend your scheduled appointment(s). It is our policy that 2 late cancellations and/or missed appointments will result in a pause in treatment, until your schedule allows the proper time.

 

Payment for Services:

• It is the client’s responsibility to verify benefits if using insurance coverage. OTC is not able to estimate associated costs as each client’s insurance plan varies. Once registered in our system the administrative staff can provide an initial co-pay expectation, though it is not until we receive an Explanation of Benefits (EOB) from your insurance carrier -after submission of the claim that a final bill can be determined. We encourage you to call your insurance provider in advance to request information about expected charges.

• A credit card must be placed on file with our office. This card will be used to charge all fees and outstanding balances for services, including missed appointments and late cancellation fees. Fees may be charged to the credit card on file in increments of the balance due. Please note that our system does not notify you prior to your card being charged for outstanding fees. You are able to log into our portal to view all charges and payments.

• Co-pays and/or other fees for service will be billed on the morning of or within 24 hours of the date of service. If you prefer to use a different method of payment from the credit card on file please notify our administrative staff, prior to the date of service. If a provider does not accept or participate in the client’s insurance plan, or the client chooses not to utilize insurance benefits, services provided are self-pay (fee for service) and payment is due in full at the time of service. 

• Should an account become delinquent and collection becomes necessary, the undersigned agrees to be responsible for attorney's fees of 33 1/3%, interest at 18% per annum from the last date of payment and any and all applicable court costs. Delinquent accounts will be turned over to our attorneys at which time any and all civil penalties as provided in Section 8.01-27.1 of the Code of Virginia (1950) will be imposed. You also waive the benefit of Homestead Exemption or other exemption under insolvency laws.

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Additional Fees: 

The cancellation policy is as follows. 

• You must cancel your appointment NO LATER than 24 hours BEFORE your scheduled appointment time. If your appointment is not canceled within 24 hours, or you do not attend your appointment, you will be charged the missed appointment fee according to the following schedule: $80.00  for an appointment with a Licensed Therapist, $140 for a Psychiatric Nurse Practitioner Appointment, $500 for a Psychological Evaluation Appointment, or $100 for a intake or therapy appointment with a Psychologist, $60 for an appointment with a Provisionally Licensed provider.

• The client is fully responsible for these fees, as insurance companies will not cover missed or canceled appointment fees. You are still responsible for this fee even if the reminder service does not call/email to remind you of your appointment. Additionally, this fee applies for current clients who miss or late cancel an appointment with a new service provider at OTC (e.g. if you currently receive therapy services and miss an appointment with a nurse practitioner).

 

There are fees associated with requests for paperwork completion, letter or document writing (excluding school notes), and/or medical records requests. Our team will discuss these fees with you prior to providing documentation to ensure agreement of associated fees, and provide an estimated dollar amount. All fees must be paid at the time of receipt of documentation. It is mandatory that all outstanding fees are paid prior to your next scheduled appointment. Failure to comply with these terms may result in cancellation of your next scheduled appointment. If you are unable to pay a balance, or are in need of a payment plan- we offer Care Credit as an option for payment plans, please call our billing manager to discuss options. 

• Paperwork such as FMLA, disability forms, court letters, etc. will not be completed until at least 3 appointments have occurred. 

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Communication with Providers: 

• Providers will make every effort to return phone calls and/or emails within 48 business hours, but neither the provider nor support staff guarantee any particular response times. 

• Email should not be utilized when the information is time sensitive. Instead, clients may call the main office phone number, 804-398-8401.

• The client understands that email and phone communication are not a substitute for health care services or evaluation. An appointment must be requested to assure appropriate treatment and recommendation. 

• OTC makes every effort to ensure that email communication is HIPAA secure. Clients understand that there is a risk in sending private health information electronically as it might be subject to exposure or loss, and therefore agree to limit the use of email communications for such correspondence.

• Contact between sessions should be limited to confirming or changing appointment times or billing questions. Your provider may discuss with you if they offer alternative methods for contact between sessions in addition to those described above. 

• You authorize us to use text and/or email as a way to communicate with you regarding appointment or payment issues. Your provider will speak directly with you about methods of communication regarding clinical concerns. Please note that all text and email messages will become a part of your healthcare record.

• Our providers will not utilize social media as a method of communication or contact with you and you agree not to request or follow your provider on their private accounts. This is intended to both protect your privacy and maintain the integrity and confidentiality essential to the therapeutic relationship.

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Emergency Policy- the Client and any Provider each understand and agree:

• Neither OTC or the provider provides emergency services.

• If the Patient is experiencing a psychiatric emergency, a life threatening emergency, and/or medication side effect causing shortness of breath, heart problems, severe rash, or other life-threatening symptoms, please call 911 or go to your nearest emergency room.

• The Provider or support staff may be able to contact your medical provider regarding medication emergencies during established business hours, but this is not guaranteed, and generally will not be addressed outside of normal business hours.