General Policies

Commercial Insurance and Payment

· Please review and know your co-pay and applicable deductible as described in your health insurance policy manual. Any and All Payments are required at the time of your visit – before seeing Bradley Why (this includes insurance cards that say you do not pay the provider at the time of the visit).

· Deductibles are your responsibility and required prior to appointments.

· We do not bill your insurance company first when you have a deductible.

Billing

· A valid credit or debit card is required and kept on file for unpaid balances over 60 days. This card will also be charged $125.00 for missed appointments/late cancellations, as per our policy and $25.00 for off schedule medication refills.

· Any outstanding balances must be paid prior to your appointment.

· On rare occasions it has been necessary for us to employ a third party billing agency to collect unpaid balances. Service fee surcharges for collections are added to delinquent accounts.

Appointment Cancellations and No Shows

· 48 hours notice is required for cancellations or rescheduling of appointments. Cancellations that are made inside of 24 hours of the appointment time are considered “late cancellations.”

· Monday appointments that are cancelled on Friday – Sunday are considered late cancellations as we are closed on Friday’s.

· No Show and Late Cancellations are charged $125 for medication checks and $225 for evaluation and extended appts directly to your credit/debit card that is on file.

Medication Refills Outside of Scheduled Appointments

· Follow-Up appointments are scheduled at particular times to evaluate the safety and effectiveness of medications that you are taking.

· Appointments are frequent during medication starts and changes but become less frequent as treatment progresses.

· Refills requests due to missed appointments are called in to your pharmacy after your appointment is re-scheduled. A $25 service fee is required.

Medication Changes

· Appointments are a time to have detailed discussions about your treatment progress; medication effectiveness and information gathering in order provide the best care. Your appointment is a time specifically carved out to re-evaluate your response to treatment and to talk about any concerns, ask questions and for you to be heard – your opinion about medication that you are taking is expected and necessary to help steer your treatment – you are the center of your treatment. Prior to leaving, a verbal or written guideline is provided about what you should expect while starting or changing medication.

• If you are having problems, questions or side effects from medication, we encourage you to call the office to discuss this .

· Medication changes, switching, increasing or decreasing doses, adding other medications are only discussed during face-to-face appointments.

· We do not provide detailed medication consultations over the phone.

Disability/FMLA and Official Treatment Documents

· Documents are prepared on a case-by-case basis for established patients and are billed prior to completion.

· We do not meet with patients for the sole purpose of gaining FMLA or Disability.

· Official letters of endorsement regarding mental illness or psychiatric care for court purposes, legal purposes, employment etc. for new patients cannot be adequately determined during the first several months of treatment

Treatment Policies and Agreements

· Give 48 hours notice in the event that I cannot make an appointment.

• Pay co-pays and balances at each appointment.

· Abstain from using illicit drugs while being treated in our office.

· I understand that falsifying mental health symptoms in order to gain a prescription for controlled substances is a felony offense. The Office of Drug Diversion and The DEA will be notified.

· I understand that medication refills and telephone medication checks are not done over the phone or by electronic means.

· Medication that needs to be called in off-hour due to cancelled or no show appts are charged $225.00.

· Communicating clinical or necessary information (documents, charts, medication records, evaluation forms, etc.) may be sent to: [email protected]

· Controlled Substances that have been stolen, destroyed, lost or misplaced will NOT be refilled. These medications are to be handled with diligence and responsibility and kept in a safe, secure place.

· Random medication counts and drug screening if there is suspicion of abuse, misuse or illicit drug use in conjunction with controlled substances being prescribed to you.

· Taking medication as prescribed; not changing doses or taking more medication than is prescribed – Increasing the dose or taking more medication that have been prescribed without communication to us, will result in your immediate discharge.

· Attending scheduled appointments is expected. 2 or more no showed or late cancelled appointments inhibits a responsible treatment approach and may result in your discharge from treatment.

A valid credit card is required for ALL commercially insured patients. This card will only be charged for missed appointments as outlined in our policy and/or for unpaid balances. You will be notified about any charges and provided with a receipt.

I authorize Bancroft Behavioral Health, Inc. 5610 Kirkwood Highway Wilmington, DE 19808 Fax: 302-502-3257 Facility Phone: 302-502-3255

To disclose: Psychiatric and Medical Treatment Notes, Labs, Medications, Imaging studies, Opinions, Therapeutic treatment and relative history. Unrestricted communication is authorized between Bancroft Behavioral Health, Inc. and the authorized agency, hospital, attorney or other provider listed below.

*It is our aim to collaborate with everyone involved in your treatment so that we may provide the best treatment*

Please list the name(s) of the person(s) or organization(s) for information exchange:

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to the health information management department. I understand that the revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire on the following date, event, or condition: _________________. If I fail to specify an expiration date, event, or condition, this authorization will expire 1 year from the date signed. I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed, as provided in CFR 164.524. I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, I can contact the authorized individual or organization making disclosure. I have read the above foregoing Authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

I acknowledge that I have received, have read (or have read to me), and understand the “Client Information” packet and/or other information about the services that I am considering. I have had all my questions answered fully.

I do hereby seek and consent to take part in the treatment by Bancroft Behavioral Health, Inc. I understand that developing a treatment plan with this facility and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I also consent to drug screens to determine the use of illicit drugs which may interfere and/or interact with psychotropic medication. Failure to comply with random drug screens may result in discharge from treatment.

I am aware that I may stop my treatment with this facility at any time. The only thing I will still be responsible for paying is for the service that I have already received. I understand that I may lose other services or may have to deal with other problems if I stop treatment (for example, if my treatment has been court-ordered, I will have to answer to the court).

I am aware that an agent of my insurance company or other third-part payer may be given information about the type(s), cost(s), date(s) and providers of any services or treatments I receive. I understand that if payment for the services I receive here is not made, the provider(s) may stop my treatment.

My signature below shows that I understand and agree with all of these statements.