DEMOGRAPHIC INFORMATION

I authorize and request the disclosure of all protected information for the purpose of review and evaluation to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. I request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

• Admission & Intake Data
• Clinical Needs 
• Continuing Care Recommendations
• Dates of Treatment
• Diagnosis
• Discharge Plans
• Evaluation Summary
• Lab Reports
• Medication Management
• Progress Notes
• Psycho-Social
• Telephone & Written Communication
• Treatment Plans

This protected health information is disclosed for the following purposes:

• Referral to other services
• Coordination of Care
• Verbal Communication
• Transfer of Care
• Consultation
• Other

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse.

I authorize the release or disclosure of this type of information.

By signing below, I acknowledge that I am aware of the confidential and/or privileged nature of the information being disclosed, and understand the benefits and/or disadvantage of disclosing such information. I hereby release above Facility, its affiliates and its agent and representatives, (including collection agencies) from all legal liabilities that may result from the release of this information according to this request. I may revoke this authorization at any time. Revocations to this authorization must be presented in writing. Revocation will not apply to information disclosed prior to receiving a written revocation. I understand that SSPC will not condition my treatment, payment, enrollment or eligibility for benefits on whether I provide this authorization.

I authorize and request the disclosure of all protected information for the purpose of review and evaluation to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. I request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

• Admission & Intake Data
• Clinical Needs 
• Continuing Care Recommendations
• Dates of Treatment
• Diagnosis
• Discharge Plans
• Evaluation Summary
• Lab Reports
• Medication Management
• Progress Notes
• Psycho-Social
• Telephone & Written Communication
• Treatment Plans

This protected health information is disclosed for the following purposes:

• Referral to other services
• Coordination of Care
• Verbal Communication
• Transfer of Care
• Consultation
• Other

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse.

I authorize the release or disclosure of this type of information.

By signing below, I acknowledge that I am aware of the confidential and/or privileged nature of the information being disclosed, and understand the benefits and/or disadvantage of disclosing such information. I hereby release above Facility, its affiliates and its agent and representatives, (including collection agencies) from all legal liabilities that may result from the release of this information according to this request. I may revoke this authorization at any time. Revocations to this authorization must be presented in writing. Revocation will not apply to information disclosed prior to receiving a written revocation. I understand that SSPC will not condition my treatment, payment, enrollment or eligibility for benefits on whether I provide this authorization.I acknowledge that SSPC will coordinate with my PCP to facilitate the appropriate delivery of health care services.

I authorize and request the disclosure of all protected information for the purpose of review and evaluation to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. I request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

• Admission & Intake Data
• Clinical Needs 
• Continuing Care Recommendations
• Dates of Treatment
• Diagnosis
• Discharge Plans
• Evaluation Summary
• Lab Reports
• Medication Management
• Progress Notes
• Psycho-Social
• Telephone & Written Communication
• Treatment Plans

This protected health information is disclosed for the following purposes:

• Referral to other services
• Coordination of Care
• Verbal Communication
• Transfer of Care
• Consultation
• Other

I authorize and request the disclosure of all protected information for the purpose of review and evaluation to improve assessment and treatment planning, share information relevant to treatment and when appropriate, coordinate treatment services. I request that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including the following:

• Admission & Intake Data
• Clinical Needs 
• Continuing Care Recommendations
• Dates of Treatment
• Diagnosis
• Discharge Plans
• Evaluation Summary
• Lab Reports
• Medication Management
• Progress Notes
• Psycho-Social
• Telephone & Written Communication
• Treatment Plans

This protected health information is disclosed for the following purposes:

• Referral to other services
• Coordination of Care
• Verbal Communication
• Transfer of Care
• Consultation
• Other

I understand the information to be released or disclosed may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV), and alcohol and drug abuse.

I authorize the release or disclosure of this type of information.

By signing below, I acknowledge that I am aware of the confidential and/or privileged nature of the information being disclosed, and understand the benefits and/or disadvantage of disclosing such information. I hereby release above Facility, its affiliates and its agent and representatives, (including collection agencies) from all legal liabilities that may result from the release of this information according to this request. I may revoke this authorization at any time. Revocations to this authorization must be presented in writing. Revocation will not apply to information disclosed prior to receiving a written revocation. I understand that SSPC will not condition my treatment, payment, enrollment or eligibility for benefits on whether I provide this authorization.

MS Legacy & Stepping Stones Psychiatric Care is a private psychiatric practice that accepts most major insurance companies and self-pay patients. It is the responsibility of the patient to verify outpatient mental health coverage for your specific policy to ensure coverage for your services.

Highmark – Blue Cross Blue Shield – UPMC – Self Pay

• Co-payment or balances are due in full at time ofservice
• Special financial arrangements must be discussed prior to your appointment.
• Parents/Guardians are financially responsible for payment for services provided to minors, or other legal dependents.

Payment for Services:

Every effort is made to ensure your insurance company makes payment. However, they make the final determination. I agree that I will be responsible for any services received that are not covered or denied by my insurance plan

I will provide full and accurate insurance information in advance of my appointment and bring my insurance card at the time of my appointment. I understand that insurance billing is provided by my healthcare provider as a courtesy, but I remain the responsible party. I understand that if my insurance company has not responded after 90 days, I will receive a statement. I agree to pay my balance in full at that time. I understand that I will be reimbursed promptly if and when the insurance payment arrives. I understand that I am responsible for payment of any balances on my account. If payment is not received within 90 days, your account will be turned over to collections. We have the option to pursue all lawful collection procedures available and the patient/parent will be responsible for all the reasonable costs of collection, including attorney’s fees incurred, if any. The minimum collection fee will be 50% of the total account balance. Unwillingness to pay may result in termination of services.

Policy for Missed Appointments and Cancellations:

Appointment times are reserved exclusively for you; if you do not cancel your appointment, you will be charged $40.00 for the scheduled time. To avoid any missed appointment or cancellation fees, please call 24 hours in advance to make any changes to your appointment. I understand that I must give proper notification to cancel an appointment to avoid any late cancellation or missed appointment fees. I agree to call at least 24 hours in advance to cancel or change my appointment. For Monday appointments, I will call the previous Friday by noon.

Your signature verifies your understanding of the financial responsibility you may have for services rendered during your course of treatment.

Please read the following information regarding the agreement between the healthcare provider, and the patient. Please initial each section, your initials constitute that you accept the policy in this agreement.

I request treatment for myself or for the individual for whomI am the legal representative at MS Legacy which may include diagnostic evaluation, psychotherapy, medication management, and treatment for any medical, emotional, and behavioral problems which may be found to exist. The treatment was explained to me in detail and I understand that I must communicate freely with my psychiatrist and/or counselor and not withhold pertinent information regarding my health so that the best course of treatment can be prescribed.

Patient Rights

I certify that I have reviewed a copy of my rights as a patient of Stepping Stones Psychiatric Care. Any questions regarding those rights have been address with staff.

Liability

In consideration of services rendered, Client agrees to hold MS Legacy, blameless for any liability due to an accident, illness, injury, or incident, which may occur to Client while receiving outpatient services. Client also agrees to hold MS Legacy free from all liability for any losses through fire or theft. Client agrees, if hospitalization or extensive medical care is needed, MS Legacy is not required to assist the client in obtaining appropriate medical attention. Further, the family, guardian, or Client will assume all liability for any medical expenses, hospital care, or other expenditures without liability to MS Legacy. _

Request for Records

Requests for records are received from various sources. Attention to these requests will only occur when we have received a signed (by patient or parent) release of information form. Records are copied at $25 plus postage and billed directly to you. Please allow two weeks for this request to be processed.

Letters

Letters and forms are often requested by patients (or their parents) to be sent to schools, employers, etc. We do not complete forms for Disability.

Prescriptions & Refills

MS Legacy requires 7 calendar days of notice for medication refills due to special circumstances; as our Benzodide Agreement states, patients need to be seen to receive medication refills . Without notification within 7 days, MS Legacy cannot guarantee that refills will be received by the pharmacy in time to prevent the medication from running out. MS Legacy will not provide new prescriptions if the originals are reported lost, stolen, or are not filled before the expiration date.

Confidentiality

I have further been assured that any information, knowledge, or records associated with said Client are subject to release only by my informed and written consent or by a court order, except in instances of medical emergency, suspected child or elder abuse or neglect, or risk of harm to self or others. Your confidentiality and privacy are protected by the following Federal guidelines: Code of Federal Regulations (CFR 42 Part2) and the Health Insurance Portability and Accountability Act (HIPAA).

Discrimination Policy

No person will be discriminated upon based on gender, race, religion, age, national origin, disability (mental or physical), sexual orientation, sexual preference, medical condition, including HIV diagnosis or because an individual is perceived as being HIV infected, or any other characteristic. Consent for treatment is made with informed consent, and as such, consent may be revoked and services discontinued at any time.

Permission to Leave Voice Messages

Initialing here gives permission for MS Legacy to leave voicemail message regarding appointments and other necessary information. Discretion will be used in disclosing sensitive materials through voicemail communication. Please initial here to give permission to leave voicemail messages.

Involuntary Termination of Treatment

Multiple causes for involuntary discharge exist. Causes for involuntary termination include, but are not limited to: verbal/physical aggression towards staff members or other patients, harassment of staff members or other patients, threats towards others, illegal activity related to treatment, and destruction of property. If MS Legacy receives information that a patient is receiving prescriptions by other doctors than those with MS Legacy, MS Legacy reserves the right to terminate treatment immediately and involuntarily. If a patient misses any 3 appointments (with the therapist or psychiatrist) within any 4 month span of time, MS Legacy reserves the right to terminate treatment. All patients that receive an involuntary termination of treatment will be provided with written notice and referrals for continued treatment.

Consent for Treatment and Consultation

I authorize and request that Muhammad I. Shaikh, M.D. and MS Legacy to carry out behavioral health treatments, and/or diagnostic procedures that now or during the course of my care as advisable. I understand that the purpose of these procedures will be explained to me upon my request and are subject to my agreement. I also understand that while the course of treatment is designed to be helpful, it may at times be difficult and uncomfortable.

Your signature below indicates that you have read this agreement and agree to its terms and also serves as an acknowledgement that you have received the HIPPA notice form described above.

As a client receiving services from MS Legacy, your Client Bill of Rights will include:

You have a right to be treated with dignity and respect.

1. You have the right to unrestricted and private communications inside and outside this facility including the right to make complaints and have your complaints heard and adjudicated promptly.
2. You have the right to participate in the development and review of your treatment plan.
3. You have the right not to be subjected to any harsh or unusual treatment.
4. You have the right to be informed of diagnostic and treatment procedures, their risks and their costs, that are available to you and which would aid in your recovery from mental illness. You have the right to be informed of the reasons and factors involved in recommending a procedure of choice.
5.  You have the right to be informed of the nature of material about to be released to others (or obtained) when you are requested to sign a release of information.
6. You have a right to have your records treated in a confidential manner in compliance with the laws of the Commonwealth of Pennsylvania.
7.  You have the right to courteous treatment from staff at all times.
8.  You have the right to be kept safe from injury while in the auspices of the practice.
9. You have the right to voice complaints or appeals about the insurance company or the care provider.

I (we) have received from MS Legacy staff a clear explanation of my (our) rights in simplest terms.
I (we) have received a written copy of these rights. I (we) acknowledge a clear understanding of my (our) rights.

The use of the above medications may cause addiction and is only one part of the treatment for the above conditions, -e.g., anxiety, depression,etc.

The goals ofthismedication (s) is/are to improvemy ability to work and function at home and to assist with managing symptoms.

I have been informed that:

1. If I drink alcohol or use street drugs, I may not be able to think clearly, and I could become sleepy and risk personal injury or death.
2.  I may get addicted to thismedication.
3.  IfI oranyone inmyfamilyhas a historyofdrugoralcoholproblems,there isa higherriskofaddiction.
4. IfI need to stop thismedication, I mustdo so slowly,orI may get very sick.

I agree to the following:

• I am responsible for my medications. I will not share, sell or trade my medication. I will not takeanyone else’s medications.
• I will not increase mymedication until I speak with my doctor.
• My medication will not be replaced if it islost,stolen, or used up soonerthan prescribed.
• I will keepall appointmentssetupwithmydoctor andotherhealthcare providers(e.g.therapist, and substance abuse treatment).
• I willbring thepillbottleswithanyremainingpillsofmymedicationtoeachvisitwiththedoctor.
• I agree to give a urine sample, if asked, to test for drug use. 

Refills

Refills will bemadeonly during regular officehours-MondaythroughThursday,9:00AM-6:00PMand Fridays 9:00AM-3:00PM. Norefills willbemadeonnights,holidaysorweekends. I must call at least three [3] working days ahead (M-F)torequesta refillonmy medication. No exceptionswillbemade.

I must keep track of my medication. No early or emergency refills will be made.

Prescriptions from Other Doctors

If I see another doctor who gives me a controlled substance medication (e.g. a dentist, E R doctor or a hospital) I must inform the doctor as soon aspossible.

Privacy

WhileI amtaking thismedication, mydoctor may need to contact other doctors or family members to get information about my care and/or use of this medication. I will be asked to sign a release for consen t to collaborate.

Effectively immediately, SSPC will be conducting random drug screenings on all patients at a minimum of two times per year as per insurance guidelines.

PLEASE NOTE: Patients with commercial insurance may receive a bill from Quest Labs as per individual insurance plans.

Drug screens are not optional. If selected, a patient will be required to provide a urine sample prior to being seen by the physician. SSPC has the right to discharge a patient refusing to participate in random drug screenings.

Drug screening results that are inconsistent with current medications, either prescription medications are absent or medications that are not prescribed are present, may lead to one of the following:

• Patient may be subject to additional random drug screenings.
• Patient may be asked to perform a drug screening at each visit.
• Patient may be discharged, depending upon nature of results.

In response to providing optimal Telehealth services, Stepping Stones Psychiatric Care continues to implementing measurements to protect your privacy and follow through with HIPAA regulations.

Our service providers: Psychiatrist, PA’s & Therapists, will send a link to your email or a text message to your “best” phone number in the system to connect with you via our HIPAA compliant ICANotes computer service. This will allow access to video/voice communication and ensure a confidential and protected session appropriately.

• The Psychiatrist, Physician Assistants & Therapists will reach out to you from our current office location in Bridgeville, to ensure privacy and client information protection & confidentiality.
• We know that life is busy, and you are important to us! We recommend that you find a quiet, private and confidential area where you can actively participate and engage in your session and make the best of it without being disrupted or bothered by onlookers, kids, coworkers, etc.!
• It is also recommended that you ensure that any updates in your computer, cellphone or any other devices that you might use for the session have been completed so that they do no attempt to update in the middle of the session while you are talking.
• Only the service provider and the patient [and guardian in case of a minor] should be present.
• By scheduling, answering the call or connecting via the link sent to your email you are consenting to actively participating in the session.
• Because technology can be unpredictable at times - If the video service is not available, signal isn’t optimal, we can’t hear you, etc., a regular phone call will be attempted. If neither service is  successful [possible delays in service, need to travel, or risks associated with not having the services] the appointment can be rescheduled for another day as a Telehealth appointment or an In-person appointment.
• As a patient it is your right to accept or decline participating in Telehealth services in each session.
• If that was the case, we do have the option of In-person appointments to facilitate interaction and avoid technology disruptions.

Here at Stepping Stones Psychiatric Care our psychiatrist works with a scribe that assists in documenting your sessions. The following is consent that you are willing and okay with a scribe being present during your sessions both in person and telehealth. You are able to revoke this consent either verbally or in writing at any time with any staff member.

****Patient has been informed of the use of a scribe during their treatment session(s) and has provided verbal agreement to participate in treatment. These sessions can be offered either “IN PERSON” or “TELEHEALTH” and this consent will be applicable to both services.

Please indicate if the patient has taken any of the following psychoactive medications or is currently being prescribed them by another practice. In the blank box next to the medications, please indicate an “H” for Helpful, and “NH” for not helpful, for each medication the patient has previously tried. If the medication has not been tried by the patient, please leave the box blank.

If the patient is enrolled in elementary school, middle school, or high school, please answer the following questions. If the patient is not enrolled in any of the above, please skip this section and move on to “History of Abuse and Traumatic Events”.