Release of Patient Health Information (PHI)
We at Solace Behavioral Health want you to know how your Patient Health Information (PHI) is going to be used in this office. As your mental health provider, it is our goal to communicate with your referring and primary care physician in order to keep them actively involved in your care. In some cases, we may release your Patient Health Information (PHI), such as your demographics, progress notes, diagnosis, lab results, treatment plans, billing history, and prescription information. Provide your referring and/or primary care physician down below that you would like involved in your care.
Payment is due at the time of service. We encourage you to research your health coverage benefits prior to arriving to your appointment, as you are responsible for co-pays, co- insurance, deductibles, and any other unpaid balance on your account. Keep in mind, that if you are not prepared to pay these fees at the time of your appointment, we may need to reschedule.
Consent to Obtain External Prescription History
I authorize the providers at Solace Behavioral Heath to view my external prescription history though the RxHub service. I understand that all of my prescription history that have been prescribed by other unaffiliated medical providers may be viewable through the RxHub service. I acknowledge that my prescription history may be viewed by my provider and staff at Solace Behavioral Health.
All patient copayments and coinsurance are expected at the time of your visit. If you have an outstanding balance with our office, you will be required to pay the balance in full or will need to reschedule your appointment.
Our office will bill your insurance company for any services rendered toward your care. Any remaining patient responsibility will either be billed to you or collected at the time of your next visit. Our policy requires that all outstanding balances be paid in full and your ledger is clear within thirty (30) days of treatment.
As a patient, you have a right to appeal any payment decisions made by your insurance carrier. As a patient, it is your responsibility to contact your insurance directly regarding any disputes.
It is your responsibility to keep your patient account clear and current. Any delinquent accounts will be sent to collections after 90 days. Additionally, you may be assessed late charges and interest for any outstanding balances.
Health information is generated whenever you receive services. We are required by law to maintain the privacy of your protected health information and to provide you a notice of our practices. Below is an overview of how that information can be used and disclosed. This legal disclosure has been simplified for your convenience.
Within the Practice (Solace Behavioral Health, LLC)
- Treatment: Coordination of care with other health care professionals for the purposes of evaluating, diagnosing and treatment of your medical condition.
- Payment: Collecting payment from your health plan or from other sources that may be paying for your services.
- Health Care Operations: To support day-to-day activities and management of the practice outside the Practice
- Law Enforcement: To support audits, inspections, investigations and to comply with mandates.
- Correctional Institutions: Facilitate continuation of your care in the event you are incarcerated.
- Judicial/Administrative Proceedings: In compliance with your request or legal court mandate.
- Victims of abuse, neglect, or domestic violence: As relates under Florida Law to protect at risk individuals or potential victims.
- Public Health Reporting, Oversight Agencies, Coroners, Medical Examiners, Specialized Government
- Agencies and Funeral Directors as required by law.
Third Party Vendors
- Any vendor (not an employee) who, on behalf of Solace Behavioral Health, LLC, (1)Performs a function involving the use or disclosure of individually identifiable health information, PHI, (other than incidental) including claims processing or administration, data collection/analysis, processing or administration, utilization review, quality assurance, billing, benefit management, practice management, and repricing or (2)Provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services to or for Solace Behavioral Health, LLC, where the provision of the service involves the disclosure of individually identifiable health information from Solace Behavioral Health, LLC.
- Appointment Reminders, Workers Compensation, Your Legal Representatives and Workers Compensation
- Research: Only when approved by an IRB and protocols have been followed.
- Other Uses: Requires specific written authorization. You can change your mind, but this may not undo disclosures made during the period of authorization.
Individual rights under Federal Privacy Standards include:
- Use and disclosure of protected health information
- Confidential communications about your treatment with your provider
- To inspect, amend, submit corrections to and copy your protected health information. Filling out a form available at our office can do this.
- Tracking of disclosure of your protected health records
- Provided a copy of this notice
You may submit any concern or complaint about our privacy practices. If you believe that your privacy rights have been violated, please send a letter or email to the address above. You will not be penalized or otherwise retaliated against for filing a complaint.
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes may reflect changes in state and federal regulations. Only the latest policies and practices will be applied and available for your review at our office. If you wish to see the actual legal language, please contact us.
I, the undersigned, voluntarily give consent to my Solace Behavioral Health, LLC medical professional to provide and perform diagnostic procedures and treatment(s) and/or services as deemed advisable and necessary for the diagnosis and/or treatment of my condition(s) or to maintain my health. I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatment or examination in the office.
Assignment of Benefits
I hereby authorize my Solace Behavioral Health, LLC practice location to release any medical information necessary to process any and all claims for reimbursement on my behalf. I authorize payment to be made directly to Solace Behavioral Health, LLC (or named physicians or affiliates) for services rendered. I also authorize payment of government benefits to the physician (entity) and any payments related to cross-over medigap insurers. I request that payment of authorized secondary insurance be made either to me or on my behalf to the above-named entity. I understand that I am financially responsible for all charges if they are not covered by my insurance. In the event of default, I agree to pay all costs of collections and reasonable attorney’s fees. I certify that the information I have reported with regard to my insurance coverage is correct. I further agree that a copy of this agreement shall be considered as effective and valid as the original.
Our providers only see one patient at a time so that each patient has their full attention, and only see a limited number of patients per day.
Cancellations or rescheduling of appointments made over 24 hours in advance will be appreciated, even if you do this through our messaging services.
Cancellations made less than 24 hours and No – Shows are subject to a fee as below:
- 1st Missed Appointment: $25.00
- 2nd Missed Appointment: $50.00
- 3rd Missed Appointment: Automatic Discharge
In the event of a true emergency, the cancellation policy does not apply. Documentation will be required.
Controlled Substance policy
Before a new patient receives the first prescription from one of our physicians, our clinic record must contain: past medical records, urine drug screen, clear E-Forcse search results and, a completed controlled substance contract.
Medical records: New patients must provide medical records documenting previous prescriptions of controlled medications if you are transitioning care to our practice. We strongly recommend that you obtain relevant medical records from previous providers. The patient is responsible for having this information sent to our office PRIOR to your first appointment. If you do not have previous medical records, alternative medications will be explored prior to any controlled substances.
Urine drug screen: New Patients must pass a urine drug screen prior to receiving any controlled substance scripts. We do NOT issue any controlled substance scripts if there is an illicit drug or non- prescribed medication present in your system. Our tests are designed to detect specific synthetic opioids along with morphine/codeine, benzodiazepines and drugs of abuse such as amphetamines, THC, and cocaine. It will also detect many common prescription meds such as tramadol, cyclobenzaprine, and TCAs. There are NO exceptions to this policy.
Clear E-Forcse Report: All patients will be monitored closely through the Florida Prescription Drug Monitoring Program. We utilize this monitoring program to encourage safer prescribing of controlled substances and to reduce drug abuse and diversion. We will NOT prescribe any controlled substances if the E-Forcse reports displays inconsistent information, filling medications at multiple pharmacies, controlled substance medications issued by multiple doctors, etc. All information that you report to our clinical team must be consistent with this report.
All patients receiving a controlled substance will need to meet the requirements listed above for new patients. In addition, established patients already received a controlled substance must adhere to the terms of the signed controlled substance contract throughout treatment. Failure to comply with drug testing requirements will result in immediate discharge from the practice. All scheduled and random urine drug urine screens must come back negative for illicit drugs and non-prescribed medications throughout your treatment at Solace Behavioral Health. There are NO exceptions to this policy!
Under NO circumstances will additional scripts for controlled substances be issued for the following:
- Lost prescriptions: No lost prescriptions will be replaced.
- Stolen Prescriptions: Must file a police report in order to be considered for a new script.
- Early Refills: No early refills will be issued.
Controlled substances can be highly dangerous. If they are not used as prescribed, they can cause serious damage, addiction, and possible overdose. Due to these dangers and risks associated with controlled substances, it is extremely important that you understand our policy.