Financial Policy 

Agreement Payment for services provided by the Lotus Timshel Collaborative Group is due at the time that services are rendered. If the patient is covered under insurance, payment of any applicable copayment, co-insurance, or deductible is due at the time of service. If Lotus Timshel Collaborative Group is not contracted with the insurance, payment for services is due in full at the time that services are rendered unless you are set up for billing and payment via headway for this practice. Otherwise, Insurance will be billed on your behalf, and you will be reimbursed any applicable credits. Lotus Timshel Collaborative Group makes every effort to verify your coverage with your insurance. However, you are strongly encouraged to verify your benefits and coverage to ensure you fully understand what is covered. You agree that it is your responsibility to inform the practice of any changes to insurance plan prior to each of your visits, or you may be responsible for the full fee. Some services may not be covered by health insurance. You agree to be fully responsible for payment for all services that are not covered by your health plan. This may include charges for telephone consultations, written correspondence, or reports in connection with a client's evaluation or treatment, including consultation or correspondence with the client, family members, past or current treatment providers, educational professionals, attorneys, courts, agencies, or others. If these charges are excluded from your coverage by your health plan, they will be your responsibility. There will be a charge of $50.00, including applicable fees from the financial institution(s) for returned checks or disputed credit card payments. All patients are required to have a credit card on file to initiate or continue care. It is your responsibility to update any expired cards. All outstanding balances are expected to be paid within 60 days. Payment plans can be provided upon request. Fees Not Billed to Insurance/Professional Services Lotus Timshel Collaborative Group may provide, on a case-by-case basis consultations with family members, past or current medical providers, educational professionals, attorneys, courts, agencies or others. Limited telephone consultation is part of routine patient care and is undertaken without charge. However, when extensive or other than routine telephone consultations, written correspondence or reports are requested or required, a charge for these services will be applied. To comply with federal laws including HIPAA, this office must have a signed authorization from the patient, or responsible party stating who we are authorized to release information to. You can contact our office or visit our website for a copy of the form. . If these charges are excluded from your coverage by the health plan, they will be your responsibility.

Listed below are the fees for professional services included but not limited to paperwork completion, consultations, court proceedings, holistic care, telepsychiatry (if not covered by insurance):

Nurse Practitioner hourly fee (minimum one hour): $325.

Requesting Records from Psychiatric Wellness Center for self/provider/ other entities To request records from the Psychiatric Wellness Center for yourself, another provider or entity we require that you complete the "Authorization to Release Medical Records from Psychiatric Wellness Center" form in entirety. Incomplete forms will not be processed and will delay your request. The cost is a $15.00 minimum processing fee and 25 cents per page to fax or copy your record and additional cost for required certified mail (postage and handling included in invoice paid prior to receipt). We do NOT email records. Processing is 8-10 business days for most circumstances. Please be aware, although you may have signed a release for communication, if you are requesting that we send records, you will need to complete the above process each time you request records to yourself or to be sent to any provider or entity, which includes primary care or change of psychiatric provider upon termination. Appointment Cancellation, No-Show, and Late Arrival Policy Psychiatric Wellness Center's policy requires patients to cancel 1 business day in advance of their appointment to avoid a cancellation fee. If their appointment is on a Monday or following a long weekend, the cancellation must be made on the previous business day. Patients are expected to arrive on time for their scheduled appointments out of courtesy to the other patients and providers/clinicians. Patients who arrive more than 5 minutes late for a 15 minute appointment, 10 minutes late for a 25-minute appointment and 15 minutes late for a 60-minute appointment, may not be seen and will be charged a late cancellation fee. Lotus Timshel Collaborative Group a $80 fee for all late cancellations, no-shows, or late arrivals. Lotus Timshel Collaborative Group makes every attempt to remain on time for appointments, however, occasionally circumstances arise that may result in an appointment delay.

Discharge Policy

At the discretion of Lotus Timshel Collaborative Group, a patient may be discharged from the Practice and their insurance notified if any of the following guidelines are not followed:

- Patient's failure to follow the recommended treatment plan or medical instructions including the Controlled Substance Agreement, if applicable.

- Patient fails to meet financial responsibilities

- The provider cannot provide the level of care necessary to meet the patient's needs

 - The member and/or member's family is abusive to the provider and/or staff.

-         The patient or provider moves out of the service area

-         Two or more no-shows, or late cancellation within 90 days or Three or more no shows within a 12 month period.

Confidentiality is a basis of mental health treatment and is protected by the law. Aside from emergency situations, information can only be released about your care with your written permission. A release is not needed for providers of Lotus Timshel Collaborative Group to consult with other providers within the Practice. If insurance reimbursement is pursued, insurance companies also often require information about diagnosis, treatment, and other important information in the Disclosure of Health Information as a condition of your insurance coverage. Several exceptions to confidentiality do exist that require disclosure by law: (1) danger to self - if there is threat to harm yourself, we are required to seek hospitalization for the client, or to contact family members or others who can help provide protection; (2) danger to others - if there is threat of serious bodily harm to others, we are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization; (3) grave disability or impairment - if due to mental illness, you are unable to meet your basic needs, such as clothing, food/water, medical care, and shelter, we may have to disclose information in order to access services to provide for your basic needs; (4) suspicion of child, elder, or dependent abuse - if there is an indication of abuse to a child, an elderly person, or a disabled person, even if it is about a party other than yourself, we must file a report with the appropriate state agency; (5) certain judicial proceedings - if you are involved in judicial proceedings, you have the right to prevent us from providing any information about your treatment. However, in some circumstances in which your emotional condition is an important element, a judge may require testimony through a court order. Although these situations can be rare, we will make every effort to discuss the proceedings accordingly. (6) in the event of a national emergency such as a global pandemic, terrorism, wartime or any other catastrophic event, Psychiatric Wellness Center will follow the Governor's Orders of each state of the patients' residence to ensure continuation of health care for reasonable amount of time. * We also reserve the right to consult with other professionals when appropriate. In these circumstances, your identity will not be revealed, and only important clinical information will be discussed. Please note that such consultants are also legally bound to keep this information confidential.

Contacting Your Provider Providers are not immediately available by office telephone, please call the office at 603-714- 9646. Calls are generally returned within 3 business days, however, for all prescription refill requests you are required to make an appointment as they are filled in session only. Always leave a phone number where you can be reached along with any updated contact information. As we are an outpatient practice we do not service walk-ins or provide crisis services. If your call is an emergency, please call 911 immediately instead of calling the office. Emergency psychiatric services are provided by all hospitals through their emergency rooms and do not require appointments. Emergency room physicians can contact your provider at any time so please provide them with their contact information. When your provider is unavailable for extended periods of time (i.e., vacation, conferences, etc.), please contact your primary care provider, if deemed necessary. Please also note that email should never be used for urgent or emergency issues. Per the agreement with your insurance provider, our practice provides on call services 24/7 for nonlife threatening and nonroutine care (please note refill requests and scheduling appointments are considered routine care). Appointment Confirmations Lotus Timshel Collaborative Group will attempt to confirm appointments via email and text upon your consent, however, it is your responsibility to know the date, time and location of your appointment. Lotus Timshel Collaborative Group has no control in regard to your phone or email connection or reliability. Inability or failure to receive a reminder or appointment confirmation via text or email is not a reason for waiver of fees. Communication for Appointment Reminders Lotus Timshel Collaborative Group may need to use your name, phone number, email address ("Contact Information") to contact you with appointment reminders via phone, text or email. If this communication is made by text, a text message will be left on your phone. If this communication is made by email, a message will be left at your email address. Messages will contain: Name of Provider: Lotus Timshel Collaborative Group, Location of Appointment, Name of Patient, Date & Time of Appointment. You have the right to refuse to give Lotus Timshel Collaborative Group your consent to use your telephone number and/or email address for appointment reminders. If you choose to give your consent, you have the right to revoke it, in writing, at any time in the future. Should you agree to communicate via email, telephone or any electronic method of communication Lotus Timshel Collaborative Group cannot guarantee that those communications will remain confidential. There is a risk that the electronic or telephone communications may be compromised. There is never a 100% guarantee that information will remain confidential when transmitted electronically.

Pharmacy: Lotus Timshel Collaborative Group may have access to your prescription history from other providers through the electronic medical record.

Legal

Legal matters requiring the testimony of a mental health professional can arise. This, however, can be damaging to the relationship between a patient and their provider. As such, we generally recommend that you hire an independent forensic mental health professional for such services.

Recording Sessions

 Patients are not allowed to record sessions or providers/clinicians under any circumstances.

Controlled Substances

Lotus Timshel Collaborative Group,  We do not believe that the majority of controlled substances are a long-term treatment. If controlled substances are prescribed on a case-by-case basis at the discretion of your provider. Our medication providers will not treat patients who are prescribed controlled substances in the same drug class they are being prescribed from another provider. Being prescribed a controlled substance by another prescriber could result in immediate termination/discharge from the practice. All patients are subject to urine drug testing per discretion of medical provider.

Inclement Weather: Lotus Timshel Collaborative Group closes for inclement weather per the discretion of the Practice and will offer telehealth sessions if able to give weather circumstances. If the Practice closes for inclement weather, it will be posted on the website. Patients are instructed to check the website for updates and will be contacted via phone if their appointment requires rescheduling.

By signing the Consent for Treatment/Acknowledgment Agreement Signature Form, you agree that you have read, agree with and understand this document, which contains information on Lotus Timshel Collaborative Group financial policy, professional fees, cancellation/no-show/late arrival, discharge policies, confidentiality, contracting your provider, confirmation and communication for appointment reminders, pharmacy, legal recording sessions, controlled substances, and inclement weather and you agree to abide by its terms during the professional relationship. You also understand and agree that our policies can change at any time and are updated on our website.

Consent for Treatment/Acknowledgment Agreement Signature:

 Consent for Treatment Patients must give voluntary consent for mental health treatment. Your signature (or that of your legal guardian) will demonstrate consent for receiving mental health treatment from the Psychiatric Wellness Center. I voluntarily consent to mental health treatment as performed by the Psychiatric Wellness Center and its employees. This treatment may include but is not limited to: assessment, screening, consultation and recommendations, psychotherapy, holistic services and psychiatric medication management. I understand that mental health treatment may involve certain risks and benefits and I understand these risks and benefits. I also understand the risks and benefits of declining treatment. I am also aware that I have the right to request information about alternative treatment options, should they exist. I have read the above information and I authorize Lotus Timshel Collaborative Group to provide mental health services to myself or this patient (if guardian). Acknowledgement of Receipt of Lotus Timshel Collaborative Group 's Policies By signing this agreement, you agree that you have read the Lotus Timshel Collaborative Group Policies, and you agree to abide by its terms during our professional relationship. Please look at our website to review our annually updated policy form. Acknowledgement of Receipt of Notice of Privacy Practices We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish. Consent Form for Communication of Protected Health Information I CONSENT to the communication for appointment reminders via text, email or phone. I have carefully reviewed this document. My electronic signature indicates my full understanding and agreement of this document.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

OVERVIEW

This notice will tell you about the ways Lotus Timshel Collaborative Group and Ailish Samuelson ("Practice," "we," or "us") may disclose health information about you and will also describe your rights and certain obligations that we have regarding the use and disclosure of your health information. Lotus Timshel Collaborative Group is a behavioral health group that is operated across multiple legal entities which are referred to by the HIPAA Privacy Rule as an "organized health care arrangement." Lotus Timshel Collaborative Group has relationships with the providers listed on this website and provides services via telehealth and at the service delivery sites of the providers listed on this website. Lotus Timshel Collaborative Group 's legal entities share protected health information with each other, as necessary to carry out Lotus Timshel Collaborative Group treatment, payment and health care operations. All of the legal entities that comprise Headway agree to comply with the terms of this Notice of Privacy Practices.

We are required by law to: make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to your health information; notify you following a breach of your unsecured protected health information; and follow the terms of the notice that are currently in effect. Although this notice is being provided to you electronically, and by signing an acknowledgment of receipt of this notice, you consent to the provision of this notice electronically, you have the right to request a paper copy of this notice. We reserve the right to change our privacy practices and the terms of this notice at any time. You may obtain a copy of the revised notice on this website. This notice is effective as of February 8, 2021.

HOW YOUR INFORMATION IS USED

We may use and disclose your health information for the purposes of providing services and quality care. For the avoidance of doubt, providing treatment services, collecting payment and conducting healthcare operations are all necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

Here are some helpful examples, but this list is not exhaustive:

Using your information for providing treatment. For example, If your treating provider cannot prescribe medications but wants to refer you to a prescriber in your insurance network, he or she may use your health information for the purpose of referring you to a prescriber who is affiliated with the Practice. The Practice or its business associates may use and disclose health information in order to verify your insurance and coverage. Example of using and disclosing your health information for collecting payment The Practice or its business associates will submit claims for reimbursement to your insurance company in order for them to pay us for the services we provide to you, which requires using your health information. Examples of using and disclosing your health information for healthcare operations The Practice or its business associates will use and disclose your health information for the review of treatment procedures and may use it to review documentation to ensure provider compliance.

For uses and disclosures for purposes other than treatment, payment and operations, we are required to have your written authorization, unless the use or disclosure falls within an exception, such as those described below. Most uses and disclosures of psychotherapy notes (as that term is defined in the HIPAA Privacy Rule), uses and disclosures for marketing purposes, and disclosures that constitute the sale of Personal Information require your authorization. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we may have already taken any action in reliance on your authorization.

DISCLOSURES THAT CAN BE MADE WITHOUT AN AUTHORIZATION

Emergencies. Sufficient information may be shared to address an immediate emergency you are facing. Judicial and Administrative Proceedings. We may disclose your personal health information in the course of a judicial or administrative proceeding in response to a valid court order or other lawful process, including if you were to make a claim for Workers Compensation. Public Health Activities. If we felt you were an immediate danger to yourself or others, we may disclose health information about you to the authorities, as well as alert any other person who may be in danger. Child/Elder Abuse. We may disclose health information about you related to the suspicion of child and/or elder abuse or neglect. Criminal Activity or Danger to Others. We may disclose health information if a crime is committed on our premises or against our personnel, or if we believe there is someone who is in immediate danger. Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These activities might include audits or inspections and are necessary for the government to monitor the health care system and assure compliance with civil rights laws. Regulatory and accrediting organizations may review your case record to ensure compliance with their requirements. The minimum necessary information will be provided in these instances. Business Associates. Practice may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, the Practice contracts with a vendor for filing claims with insurance companies. In the process of filing claims, that organization will come into contact with your information. We also contract with a vendor that collects and manages internet or other electronic network activity on our sites and services and internally encodes it so that we can determine and manage information that might be health information. All of our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

Scheduling appointments. We may text, email or call you to schedule or remind you of appointments.

YOUR INDIVIDUAL RIGHTS

Right to Inspect and Copy. You have the right to look at or get copies of your health information, with limited exceptions. Your request must be in writing. If you request a copy of the information, a reasonable charge may be made for the costs incurred. Right to Amend. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We have the right to deny your request under certain circumstances. Right to an Accounting of Disclosures. You have the right to receive a list of instances in which we have disclosed your health information for a purpose other than treatment, payment, or health care operations. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. Such accountings remain available for six years after the last date of service at the Practice. Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you. For example, you could ask that we not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. While you are in treatment, a written request should be made with your therapist. To request a restriction after therapy is completed, you must make your written request to the Privacy Officer. We are not required to agree to your request, but we will consider the request very seriously. If we agree, we will abide by our agreement unless the information is needed in an emergency or by law. Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you only by mail or at work. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests. Right to File Complaints. You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated..

EMAIL AND TEXT MESSAGES

Some of our patients prefer to communicate with their provider via email or text message. Email and text messages have inherent privacy and security risks, and you should be aware of those before using emails and text messages. Errors in transmission or interception of messages can occur. Your email or text message is not a secure communication between you and your treating provider. At your health care provider's discretion, your email or text message any and all responses may become part of your medical record. Additionally, for urgent or an emergency situation, you should not rely on email communication with providers affiliated with the Practice. In those situations, you should call 911.

❖ You will need access to the certain technological services and tools to engage in telebehavioral health-based services with your provider ❖ Telebehavioral health has both benefits and risks, which you and your provider will be monitoring as you proceed with your work ❖ It is possible that receiving services by telebehavioral health will turn out to be inappropriate for you, and that you and your provider may have to cease work by telebehavioral health ❖ You can stop work by telebehavioral health at any time without prejudice ❖ You will need to participate in creating an appropriate space for your telebehavioral health sessions ❖ You will need to participate in making a plan for managing technology failures, mental health crises, and medical emergencies ❖ Your provider follows security best practices and legal standards in order to protect your health care information, but you will also need to participate in maintaining your own security and privacy What is Telebehavioral Health? "Telebehavioral health" means, in short, services delivered via telebehavioral health rely on a number of electronic, often Internet-based, technology tools. These tools can include video conferencing software, email, text messaging, virtual environments, specialized mobile health ("mHealth") apps, and others. Your provider provides telebehavioral health services using telebehavioral health compliant and HIPAA compliant platform. ➢ You will need access to Internet service and technological tools needed to use the above-listed tools in order to engage in telebehavioral health work with your provider. ➢ If you have any questions or concerns about the above tools, please address them directly to your provider so you can discuss their risks, benefits, and specific application to your treatment.

Benefits and Risks of Telebehavioral Health: Receiving services via telebehavioral health allows you to receive services at times or in places where the service may not otherwise be available. Receive services in a fashion that may be more convenient and less prone to delays than in-person meetings. Receive services when you are unable to travel to the service provider's office. The unique characteristics of telebehavioral health media may also help some people make improved progress on health goals that may not have been otherwise achievable without telebehavioral health. Receiving services via telebehavioral health has the following risks indicated below. telebehavioral health services can be impacted by technical failures, may introduce risks to your privacy, and may reduce your service provider's ability to directly intervene in crises or emergencies. Here is a non-exhaustive list of examples: Internet connections and cloud services could cease working or become too unstable to use Cloud-based service personnel, IT assistants, and malicious actors ("hackers") may have the ability to access your private information that is transmitted or stored in the process of telebehavioral health-based service delivery. Computer or smartphone hardware can have sudden failures or run out of power, or local power services can go out. Interruptions may disrupt services at important moments, and your provider may be unable to reach you quickly or using the most effective tools. Your provider may also be unable to help you in-person. There may be additional benefits and risks to telebehavioral health services that arise from the lack of in-person contact or presence, the distance between you and your provider at the time of service, and the technological tools used to deliver services. Your provider will assess these potential benefits and risks, sometimes in collaboration with you, as your relationship progresses. Assessing Telebehavioral Health's Fit For You: Although it is well validated by research, service delivery via telebehavioral health is not a good fit for every person. Your provider will continuously assess if working via telebehavioral health is appropriate for your case. If it is not appropriate, your provider will help you find in-person providers with whom to continue services. Please talk to your provider if you find the telebehavioral health media so difficult to use that it distracts from the services being provided, if the medium causes trouble focusing on your services, or if there are any other reasons why the telebehavioral health medium seems to be causing problems in receiving services. Raising your questions or concerns will not, by itself, result in termination of services. Bringing your concerns to your provider is often a part of the process. You also have a right to stop receiving services by telebehavioral health at any time without prejudice. If your provider also provides services.

in-person and you are reasonably able to access the provider's in-person services, you will not be prevented from accessing those services if you choose to stop using telebehavioral health. Your Telebehavioral Health Environment: You will be responsible for creating a safe and confidential space during sessions. You should use a space that is free of other people. It should also be difficult or impossible for people outside the space to see or hear your interactions with your provider during the session. If you are unsure of how to do this, please ask your provider for assistance. 

Our Communication Plan: At our first session, we will develop a plan for backup communications in case of technology failures and a plan for responding to emergencies and mental health crises. In addition to those plans, your provider has the following policies regarding communications: -The best way to contact your provider between sessions is by calling the office at 518*919*8932 or via the Counsol patient portal. Your provider will respond to your messages within 3-5 business days. Please note that your provider may not respond at all on weekends or holidays. Your provider may also respond sooner than stated in this policy. That does not mean they will always respond that quickly. Your provider does not offer crisis or emergency services. Your provider only offers appropriate outpatient level of care as explained by your insurance company. - Our work is done primarily during our appointed sessions, which will generally occur during business hours of 9a-5pm depending on your provider's schedule and availability. Contact between sessions should be limited to: confirming or changing appointments, billing questions and questions regarding medication which may be deferred to your appointment.

 Communications: Please note that all textual messages you exchange with your provider, e.g. emails and text messages, will become a part of your health record. Your provider may coordinate care with one or more of your other providers. Your provider will use reasonable care to ensure that those communications are secure and that they safeguard your privacy. 

Recordings: Please do not record video or audio sessions or take pictures of the session without your provider's consent. Making recordings can quickly and easily compromise your privacy, and should be done so with great care. Your provider will not record video or audio sessions. 

Our Safety and Emergency Plan: As a recipient of telebehavioral health-based services, you will need to participate in ensuring your safety during mental health crises, medical emergencies, and sessions that you have with your provider. Your provider will require you to designate an emergency contact. You will need to provide permission for your provider to communicate with this person about your care during emergencies. Your provider will also develop with you a plan for what to do during mental health crises and emergencies, and a plan for how to keep your space safe during sessions. It is important that you engage with your provider in the creation of these plans and that you follow them when you need to. Your Security and Privacy Except where otherwise noted: Your provider employs software and hardware tools that adhere to security best practices and applicable legal standards for the purposes of protecting your privacy and ensuring that records of your health care services are not lost or damaged. As with all things in telebehavioral health, however, you also have a role to play in maintaining your security. Please use reasonable security protocols to protect the privacy of your own health care information. For example: when communicating with your provider, use devices and service accounts that are protected by unique passwords that only you.

My signing this you are consent to having Lotus Timshel Collabortive Group contact my emergency contact. I have read and agree to all of the above terms and conditions within the Lotus Timshel Collaborative Group Telebehavioral health consent to treat.