Vibrant Integrative Psychiatry PLLC has adopted the following list of patient rights.  This list shall include but not be limited to the patient’s rights to:

1. Exercise these rights without regard to sex or culture, economic, educational or religious background.
2. Considerate and respectful care.
3. To be treated in an environment that is safe for you.
4. Request and receive full information about the clinician’s professional capabilities, including licensure, education, training, experience, professional association membership, specialization and limitations.
5. Receive as much information about treatment as he/she may need to give informed consent or refuse the course of treatment.
6. Participate actively in decisions regarding his/her care.  To the extent permitted by law, this includes the right to refuse treatment.
7. Request that the therapist inform you of your progress.
8. Refuse to answer any questions or disclose any information you choose not to reveal.
9. Full consideration of privacy concerning his/her care. Case discussion, consultation, evaluation and treatment are confidential and will be conducted discreetly and with care taken to protect the patient’s identity.
10. All communication and records pertaining to his/her care are confidential and written permission shall be obtained before his/her medical records can be made available to anyone not directly concerned with his/her care, except when required by law.
11. Request the transfer of a copy of your file to any health care provider you choose.
12. Obtain a second opinion at any time about your treatment.
13. Report unethical and illegal behavior by a clinician.
14. Reasonable responses to any reasonable requests he/she may make for service.
15. Have written information about fees, methods of payment, insurance reimbursement, number of sessions, substitutions (in cases of vacation and emergencies) and cancelation policies before beginning therapy.
16. Have all patient’s rights apply to the person who may have legal responsibility to make decisions regarding his/her treatment on behalf of the patient.

I have read and understand the patient rights listed above.

The care a patient receives depends partially on the patient himself/herself. Therefore, in addition to these rights, a patient has certain responsibilities. These responsibilities should be presented in the spirit of mutual trust and respect.

1. The patient must provide accurate and complete information concerning his/her present complaints, past medical history, and other matters about his/her health, any medication including over the counter products and dietary supplements and any allergies and sensitivities.
2. The patient is responsible for making it known whether he/she comprehends the recommended course of treatment and what is expected of him/her.
3. The patient is responsible for following the treatment plan established by himself/herself and the clinician.
4. The patient is responsible for his/her actions should he/she refuse treatment or fail to follow instructions by the clinician.
5. The patient is responsible for assuring that the financial obligations of his/her care are fulfilled as promptly as possible.
6. The patient is responsible for following facility procedures.

The patient is responsible for being considerate of the rights of other patients & facility personnel.

I have read the responsibilities. I understand these responsibilities and agree with them.

I am committed to providing you with the best possible care. To make it possible to spend more time on items directly related to your care, I have adopted certain financial policies, which I will explain to you.

1. Payment by check, money order, cash and Visa, MasterCard, Discover and American Express.
2. The fees set for Ilya Ray, APRN services are considered reasonable and customary for practitioners in this area with equivalent training and experience.
3. If you cannot afford the fee or are not able to make your payment at the time of the consultation, please discuss the issue with Ilya Ray, APRN prior to the appointment.  Ms. Ray is willing to negotiate other arrangements but wants to avoid the time it takes to send multiple bills.
4. If Vibrant Integrative Psychiatry PLLC and Ilya Ray APRN are not in your insurance network, you will be provided with a claim form as a receipt with all the usual information required for insurance reimbursement.  It will be your responsibility to submit the claim to your carrier.
5. If your insurance company requests additional information, to verify the medical necessity of treatment, for example, Ilya Ray APRN will cooperate with them on your behalf and with your permission.  There may be a fee if the paperwork is excessive.
6. Ilya Ray APRN can assist you in filing a complaint with the insurance commissioner, if need be.
7. You must pay your co-payment at the time of the appointment.  The claim will be submitted to your insurance carrier for processing.
8. Any monies received by Vibrant Integrative Psychiatry PLLC from your insurance company over & above your indebtedness will be refunded to you.
9. If your insurance company should decide, for whatever reason, that a claim once paid is now denied, you will be responsible for refunding Vibrant Integrative Psychiatry PLLC for that payment.
10. Even if Vibrant Integrative Psychiatry PLLC files your claim, you are responsible for monitoring the status of the claim.
11. You are responsible to pay in full for all services provided, regardless of whether it is covered by your insurance policy or other third-party payer.
12. Vibrant Integrative Psychiatry PLLC realizes that temporary financial problems may affect timely payment of your account.  If such problems do arise, please contact the office promptly for assistance in the management of your account.
13. There will be a fee assessed of $30.00 for a returned check.
14. An interest rate of 2% per month will be charged on balances older than 30 days from the date you have been notified of the outstanding balance.  Balances more than 30 days overdue will be subject to late fees.
15. Outstanding balances may be subject to additional collection fees and court costs.
16. If you have any questions about the above policies, please do not hesitate to inquire.

I have read the financial policies of Vibrant Integrative Psychiatry PLLC. I understand these policies and agree with them.

Please remember the following points regarding your insurance coverage:

1. Your insurance policy is a contract between you, your employer, and the insurance company. Vibrant Integrative Psychiatry PLLC or Ilya Ray, APRN-FPA is not a party to that contract.
2. Vibrant Integrative Psychiatry PLLC’s fees are considered to fall within the acceptable range by most companies, and therefore are covered up to the maximum allowance determined by each carrier. This statement does not apply to companies who reimburse based on an arbitrary schedule of fees, which bears no relationship to the current standard and cost of care in this area.
3. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services that they will not cover.

We understand emergencies happen that can affect your schedule. Please call and let us know as soon as possible and we will try to work with you. If you fail to cancel a scheduled appointment with at least 24 hours’ notice, we cannot use this time for another client, and you will be charged for the entire cost of your missed appointment. A bill will be sent to clients who miss or cancel an appointment with less than 24 hours’ notice. Arrangements for payment must be made prior to rescheduling the appointment. If a client misses an appointment and/or cancels late twice (2 times) they will be subject to discharge from the practice. They will be considered for readmission after one year. Thank you for your consideration regarding this important matter.

I have read the cancellation policies. I understand these policies and agree with them.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.