We would like to take this opportunity to thank you for choosing Poehailos, Dupont, & Associates (PDA) for you and/or your family's mental health needs. We value your trust in us. It is the mission of our practice to provide you and your family with comprehensive and state-of-the-art services that are of the highest quality. As we begin our work together, it is important that you understand the philosophy and policies of our practice. Please read the following thoroughly and sign the Informed Consent statement at the end of this document. We encourage you to talk over any questions you may have with your clinician.

We are a mental health practice made up of a multidisciplinary team of professionals including Psychiatric Nurse Practitioners, Psychologists, Licensed Clinical Social Workers, Licensed Professional Counselors, and Residents in training and under supervision of licensed clinicians. Although each of these individuals may not be directly involved in your or your family's care, it is our belief and experience that a team approach lends itself to the highest quality and most efficient treatment. We have striven to put together a group of qualified and caring professionals to assist you and your family.

We take a biopsychosocial, multisystemic, and competence-based approach to assessment and treatment. The term biopsychosocial refers to the fact that people's thoughts, emotions, and behaviors are determined by a combination of biological factors and life experiences. When mental health problems arise, they may be related to biological disturbances, distressing life experiences, or frequently, a combination of both. The term multisystemic refers to the fact that though people are individuals, they are also part of a variety of larger systems. In any system, the functioning of all parts is interdependent. If one part is struggling, this likely will affect the functioning of other parts. Similarly, healthy parts of a system can often help a struggling part recover. Children are parts of various systems; first and foremost a family system, and we strongly encourage family involvement in our practice. We believe it is rare that an individual can be successfully treated in isolation. Finally, our approach is primarily competence-based rather than disease-oriented. We believe that it is generally not helpful, or accurate, to see mental illness as the result of personal or family defects. In fact, most problems originate from attempts to deal with difficult life situations in the best fashion that was available (and may have even been successful) at the time, but over the longer term has created unforeseen secondary difficulties.

We appreciate that you have taken what has likely been a difficult first step in making a mental health appointment. We applaud you for your courage in doing so. Be aware that therapy is hard work. For it to be successful, changes must come about in the way individuals think, feel, behave and/or interact with one another. Change, even when it is for the better, is difficult; it takes time and effort. The therapeutic process often involves having to acknowledge parts of our lives that are very uncomfortable or that are associated with painful feelings. This is not easy for any of us. For treatment to be successful, it will require ongoing courage and effort on your/your family's part. It will also require honesty and open communication, often about things that are difficult to face. Our clinicians realize the difficulties that you face and are here to guide/assist you through these times.

Assessment and Contracting for Treatment: Our work together begins, and may end, with an intake assessment process. As described and discussed with you at the time of your call to schedule an appointment, this may take several forms and may consist of one or several appointments. Once the intake process is complete, your clinician will discuss it with you. At that time, we will review with you and your family our findings and recommendations. It is at this point that a decision will be made together whether or not to continue with our practice for the next phase of treatment.

Payment Policy: All clients are required to have a working credit card on file prior to their first appointment. This card will be charged immediately following every appointment. If you need to change the credit card we have on file, it is your responsibility to notify our office prior to when you want a different card to be charged. The Fee Schedule is available on our website and by request, lists of our services and fees. If you have any questions about these, please ask your clinician. We accept private pay and reimbursement through some insurance companies. If we are in network providers with your insurance company, then you are required to make your co-payment at the time of each appointment. If you have insurance for which we are out of network providers, our policy is to collect the full fee from you at the time of service. We will submit the claim to your insurance and any reimbursement that may be made from them will be applied to future visits. Please note that our willingness to bill insurance companies for services provided does not minimize your responsibility to make payments for services. If payment for services is not received from the insurance company within 90 days of billing, the responsibility for that payment will be transferred to the guarantor or responsible party. Note that when you ask us to bill your insurance company for services provided, you are giving consent for us to communicate with them regarding your care (see #2 under Confidentiality below). This may involve report preparation and/or phone calls; the time spent on these will be billed to you.

If your insurance company requires authorization for our services, it is your responsibility to inform Poehailos, Dupont, and Associates prior to your visit. The client/legal guardian/guarantor is ultimately responsible for all charges incurred during the course of treatment. In the event it is necessary to take legal action to collect on an account, all costs are added to the outstanding balance.

Missed Appointments: Accepting Electronic Communication will provide the primary phone number associated with the portal to receive a text message reminder 24 hours prior to each appointment. Please note that we do not routinely call to remind you of an upcoming appointment. Billing occurs for all scheduled appointments unless a request is made to reschedule or notification of cancellation is given at least 24 hours before the scheduled appointment. If such advanced notification is not given, you are responsible for paying the full fee for the session. Insurance companies do not reimburse for missed appointments. If there are two missed appointments, future appointments may be delayed pending payment of associated fees. When you miss an appointment, it is your responsibility to call and reschedule, even if you generally have a standing weekly time slot; we cannot guarantee that such a time slot will be held if an appointment is missed without notifying our office. In general, appointments for individual and family therapy run 45-60 minutes in length at the discretion of your clinician. Medication management appointments run 15-30 minutes. It is important to be on time for your appointment; we are unable to extend your appointment time into the next hour if you arrive late. Generally, clinicians will wait 15 minutes before considering an appointment to be "missed" and cancelled. However, it is at the discretion of your clinician if an appointment for which you arrive late will need to be rescheduled or considered a missed appointment and billed as such.

Ancillary Services: Our practice provides a number of services that can supplement and enhance treatment; they are often very efficient ways of intervening productively without the need for an office visit. However, most insurance companies will only reimburse for "face-to-face" services. It is important to remember that insurance will generally not cover Ancillary Services and requesting/utilizing them is done with the understanding that such fees are billed directly to the client or guarantor. These services include:

• Consultation with parents, schools, and other agencies: Families and children are frequently involved with multiple resources and agencies in the community. While it is important to coordinate treatment as much as possible, this can be a very time consuming endeavor. In order to address this need, clinicians at PDA can provide (with sufficient advanced notice), written reports as well as telephone consultation with parents, teachers, school staff, other treatment and care providers, and other agencies. It is only at the explicit request of a parent/legal guardian that contact is made with other agencies. Fees are billed as "Report Preparation" or "Telephone Consultation" for such services. This includes any phone calls by parents/patients that require a response by a clinician (e.g. calls for advice on how to handle a situation, etc.).

• Prescription Services: If your treatment in our practice includes medications that are prescribed by one of our psychiatric nurse practitioners, they will be happy to provide you with any prescriptions needed at the time of your appointment. It is always best to check how much medication you have left at home before you come in for your scheduled visit and let your provider know at the beginning of the appointment if you are going to need any refills. Alternatively, you can phone-in a request for medication refills outside of your scheduled appointment time. However, due to the clerical and provider time involved in providing this service, a "Prescription Refill" charge will be billed to your account. If you do choose to utilize the prescription refill service, please have the following information available at the time of your call to us: The patient's full name, date of birth, the name and phone number of the pharmacy where you would like the prescription(s) filled, the medication's name, dosage, and directions on the label regarding the amount and times of day taken. Note that this service is only available during normal business hours and we ask that you call in at least five business days before you are to run out of your medication. In some cases, your provider may require that you be seen before authorizing refills. Please note that your providers may not be in the office to approve refills each day; please check with your provider about when they are available to approve refills to avoid running out of your medication.

• Record Review: At times patients come to us because they have elected to switch providers or get another opinion. In these, and other cases, they may have had multiple previous evaluations done by other professionals including mental health specialists, medical doctors, school personnel, and the like. In such cases, a review of these past evaluations can be a time saving and useful part of the assessment process. If possible, it is helpful if you provide these records to us before your first appointment. In such cases, the evaluating clinician will spend time reviewing them before you come in. As this does take time, however, and is not a face-to-face service that most insurance companies reimburse for, a "Record Review" fee will be billed to your account.

Confidentiality: As discussed above, successful treatment often requires the disclosure of some very personal, and at times uncomfortable, information. It is our policy to maintain the strict confidentiality of all clients and their records according to the law and professional ethics. In general, no information you disclose will be shared with a third party without your written consent. However, there are some exceptions regarding confidentiality which include the following:

1. Within our practice we work as a multidisciplinary team, exchanging information and consulting with each other regarding the clients we serve in order to provide the highest quality service to you that we can. This exchange of information may occur whether or not you have directly seen the clinician with whom the information is discussed. The information remains within the practice and is not shared with other (outside) individuals without your consent. If there is some reason you do not wish information to be shared within our practice, please discuss this with your clinician.

2. If you wish us to file insurance for you, you must allow us to release information required by your insurance company. Health insurance companies may require a treatment plan along with other information, including dates of service and a diagnosis regarding the condition for which you seek services. Such a diagnosis reflects an illness or condition necessitating services. Any diagnosis becomes a permanent part of your insurance records. Insurance companies will also periodically require us to provide parts of your record such as notes from appointments to confirm our compliance with their documentation guidelines. The practice has no further control over the confidentiality of the information submitted to insurance companies.

3. State law requires that any mental health provider who suspects a child may be abused or neglected must report this to the Department of Social Services. This includes suspicion of abuse or neglect to children who are not being treated within the practice of PDA. This is also true in the case of certain adults 60 years of age or older and incapacitated adults age 18 or older who are suspected of being abused, neglected, or exploited.

4. If your therapist believes you are in imminent danger of harming yourself or others, disclosure of information to appropriate persons is required to assure your safety and the safety of others. If you report that you are, or have in the past experienced neglect by a parent or other adult who is supposed to provide care for you, or if you have witnessed domestic violence within your home, the law requires this to be reported to the Virginia Department of Social Services.

5. If you report knowledge or suspicion of another person under the age of 18 having a plan to harm themselves, harm someone else, involved in activities that could cause significant harm to themselves, being abused or neglected, or is witness to domestic violence, the law requires this to be reported to the Virginia Department of Social Services.

6. If your therapist receives a subpoena or other legal request for disclosure of confidential information, he or she will contact you to find out if you want to give permission to release the information. If you do not wish the records to be released, your therapist will cooperate with your attorney in filing motions to quash the subpoena, requesting that the confidentiality of the therapy relationship be protected. However, only the court may ultimately decide whether or not the requested information or records will be disclosed. Note that any fees involved in quashing a subpoena are the responsibility of the guarantor.

7. If you are involved in any legal case in which your mental or emotional health is an issue, a judge may order the release of your medical record for the court to examine. We are required to comply with a court order.

8. There may be other situations in which release of information would be necessary or advisable. Your therapist will discuss any such situations with you beforehand. In all cases care will be taken to release only that information that is necessary to fulfill the specific legal, ethical, or professional obligation that is at hand.

Emergency/On-Call Policy: PDA does not offer crisis, emergency, or on-call services. Whether or not your clinician can see you for an emergency appointment is at their discretion and based on their availability. While under the care of PDA, if you or a family member has a mental health crisis, you can call the office at (434) 220-4686 and leave a message with your primary clinician. Please understand that not all clinicians are in the office each day and messages left on clinician's voice mail may not be answered until your clinician's return. If the situation cannot be resolved via a Telephone Consultation (for which a fee will be charged), or if you find the crisis unmanageable prior to your call being returned, it is suggested that you contact 911, the Emergency Room of Martha Jefferson Hospital at (434) 982-7150, or the University of Virginia at (434) 924-2231. The local Community Service Board (Region 10) also operates a 24-hour crisis line at (434) 972-7800. In the event of a true emergency (i.e. a situation in which someone's life/well-being may be in immediate danger) have the individual directly transported to the nearest Emergency Room/Crisis center and attempt to contact us after you have arrived.

Click here to see our Fee Schedule.

Notice of Privacy Practices

This Notice of Privacy Practices describes how we may use and disclose your Protected Health Information (PHI) in accordance with applicable law including the Health Insurance Portability and Accountability Act (HIPAA), regulations under HIPAA including HIPAA Privacy and Security Rules, and practitioner codes of ethics.

The purpose of this notice is to ensure that disclosure of PHI is made consistent with applicable laws, regulations, and health information standards, and to ensure that any disclosures of PHI are appropriate.

You have the right to:

• Get a copy of your medical record. We will provide you with a paper copy of your medical record within a timely manner. We may charge a reasonable administrative fee.

• Request corrections to your medical record. We may say no to your request and tell you why.

• Request how information is communicated to you. We will say yes to all reasonable requests.

• Ask us to limit the information we share. You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree with your request and may say no if it would affect your care. If you paid for a service or health care item out of pocket in full, you can ask us not to share that information with your health insurer. We will say yes unless a law requires us to share that information.

• Get a list of who your information has been shared with. We may charge a reasonable administrative fee to provide this list.

• Get a copy of this notice.

• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will ensure the person has this authority before we take any action.

• File a complaint if you believe your privacy rights have been violated. You can contact us at 434.220.4686 or the US Department of Health and Human Services Office for Civil Rights at 200 Independence Ave, SW, Washington, DC 20201, or calling 1-877-696-6775.

We use your PHI in different ways to treat you, run this organization, and comply with law. While the following examples may not be an exhaustive list of the different ways we would create or use your PHI, any use or creation would fall into one of the following categories:

• To treat you. We create records that include your PHI in order to provide care and treatment. We can share your PHI with other professionals within this practice. We may share your PHI with other providers or individuals outside of the practice you have consented to having your PHI shared. We use and share your PHI to provide and improve care and to contact you.

• To run our organization and communicate with other organizations. We use health information about you to manage your treatment and services. We may send you electronic communications regarding your appointments or changes to them. We will comply with your insurance company’s request to provide copies or parts your record that include PHI in order to be in compliance with their documentation requirements. We may provide PHI to other entities that request it when authorized to do so.

• To bill for your services. We may contact your insurance company to confirm your benefits and receive payments. We may give information about you to your health insurance plan or other entities so they will pay for your services with your consent.

• Comply with the law. We can share your PHI without your consent in response to a court order or as mandated by law or law enforcement. We are allowed or required to share your PHI in other ways that contribute to the public good such as public health and emergencies. We have to meet many conditions in the law before we can share your PHI for these purposes. This may include preventing or reducing a serious threat to anyone's health or safety and reporting suspected abuse, neglect, or domestic violence to the appropriate authorities, notifying a potential victim of a threat to their safety, notifying law enforcement, notifying appropriate government agencies, or arranging for hospitalization.

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services.

• We will not use your PHI for marketing purposes, and we will never sell your PHI.

• Unless required by law or previously authorized by you, we will receive your written consent before providing your PHI to anyone.

Our Responsibilities:

• We are required by law to maintain the privacy and security of your PHI.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can share your PHI, you may change your mind at any time.

• We can change the terms of this notice and the changes will apply to all the information we have about you including previously collected information. The new notice will be available upon request and be posted in our office.

• We will make a reasonable effort to use, disclose, or request the minimum amount of PHI necessary unless otherwise required by law.

Click here to download a copy of our form to release and exchange information.

Click here for a copy of the contract