Treatment Policies and Care Agreement
PLEASE READ THE ITALICIZED SECTIONS CAREFULLY, AS THEY REPRESENT YOUR AGREEMENTS IN THEIS CARE CONTRACT. YOUR INITALS AFTER EACH SECTION AND SIGNATURE AT THE END ENDICATES YOUR ACCEPTANCE OF THESE POLICIES.
As a patient of Diane Privitor Davis, Certified Family & Psychiatric Nurse Practitioner, you can expect to:
- Be treated with consideration and respect
- Be viewed as a unique and worthwhile individual with strengths as well as vulnerabilities
- Have your experiences heard with compassion and non-judgement
- Receive care in a comfortable and private setting
- Receive care that is free from discrimination or any bias
- Have appointments that start and end in a timely manner
- Be educated about your condition and options for its treatment, including non-treatment, and be involved in all decisions about your care
- Have any concerns and questions addressed in a timely manner
- Have every aspect of your care remain strictly confidential, except when the nurse practitioner is required by law to do otherwise
- Have any grievances or concerns responded to in a respectful and constructive manner
- Have access to your medical record, if requested
- Be fully informed about financial aspects of your care
- Be able to designate a health advocate to help you with decision-making in your care
- Be helped to find alternative care if you or the nurse practitioner feel that a different care arrangement is in your best interest
Office Hours and Appointments
Office hours are 9:15am to 5pm, Monday through Thursday. New patient appointments are 60 minutes and follow up visits for medication management are 20 minutes. Therapy sessions are 45-55 minutes. New patient appointments must have all the intake paperwork performed prior to being seen. These intake forms are provided in advance of the appointment.
Arrival, Cancellations and Missed Appointments
I will make every effort to arrive on time for my appointments. If I arrive late, I understand that I will be seen for the time remaining in the appointment or be worked into the schedule. If I am 15 minutes late for an appointment, I understand I cannot be seen that day and will be rescheduled. When possible, if running late, I will notify the office to let them know. I will provide 24 hours notice of cancellation or a reschedule request. If I fail to give a cancelation notice, I agree to pay $50.00 fee, which is not reimbursed by my insurance. First time patients who are more that 15 minutes late for their appointments cannot be seen that day and will be rescheduled. Insurance plans do not cover missed appointment fees. The payments are the responsibility of the patient. *See financial policy agreement for more detailed information. *
Communication
The nurse practitioner communicates with patients via email or phone. Typically, email is returned within twenty-four hours. Email should be used for non-urgent matters only. Routine calls are generally returned at the end of the clinic day, but no later that the end of the following business day. After hours calls will be answered by calling the office number at 318-816-5116. Please only call after hours if an emergency. Not for routine calls. Responses to some emails may incur a consult fee depending upon the amount of clinical expertise and time required. IF extensive medical expertise is needed, a fee of $15 will be charged for those email replies. Patient will be given the choice of advice via email for a fee or being seen in clinic for evaluation for consult. In an emergency, or in the case of suicidal or violent thoughts, patients should call 911 or go to their local emergency room. If it is an urgent call but non-life-threatening, please call our office and leave a message or follow instructions for making you email urgent. Urgent phone calls will be returned within 12 hours. I consent to nurse practitioner-patient communication via email. I understand that even when all reasonable security measures are employed, email cannot be guaranteed as entirely private and confidential, and that emails I send will be included as part of my medical chart.
Social Media and Networking
Psychiatric care works best when conducted within an environment with safe, controlled boundaries. As a matter of policy, nurse practitioners and all staff do not interact with patients on social networking sites such as but not limited to Facebook, Twitter, Instagram, Snap Chat, LinkedIn, Etc. Please do not be offended if your request to connect is declined. No medical service will be given via social media or networking sites.
TEXT AND PERSONAL CELL
If you have staff personal cell numbers, please do not text questions or requests for appointments, medication refills or any medical questions. As noted in the Social Media and Networking, psychiatric care is best within safe, controlled environment. A text or call on a person cell phone is not a safe setting. We want to keep you and your information secure, confidential and treated in the appropriate setting.
Prescription Policies
I understand my nurse practitioner will prescribe enough medication to last until the next recommended visit. I will monitor my current supply of medication and remaining refills. I will request prescription refills during my appointments. The responsibility for making a timely appointment request that ensures an adequate supply of medication is mine. If I do not meet this responsibility, I agree to pay the fees for (between-visit) routine refills or urgent refills at a fee of $15.00. Prescriptions for controlled substances such as sleep, anti-anxiety medications or ADD medications will only be provided during appointments. I understand that while being prescribed a controlled medication, I will need to be seen monthly for the first several months, and then at least every 2 months for ADD/ADHS medications and every 3 months for other controlled substances once stable, without exception. The nurse practitioner utilizes the Prescription Drug Monitoring Program to trach patients’ use of controlled substances. Misrepresentation about or misuse of controlled substances may be cause for patient discharge. I understand and agree to this office’s policies regarding prescriptions and controlled substances.
Confidentiality and Release of Medical Records
Your status as a patient and all information related to your care is treated confidentially. This office will not share or release health information about you to anyone, including your spouse/partner, without your written consent. There are legal exceptions to this rule, which you can review with the nurse practitioner. I have had any questions related to confidentiality satisfactorily answered. I agree to keep a current consent-to-release-information form on file with this office. I will supply my nurse practitioner with all prior mental health record and select physical health records that she requests. I agree to keep my nurse practitioner updated about changes in my health conditions and about medications being prescribed to me by other doctors. I understand that I have the right not to share my medical records, but that this may jeopardize my overall care and may be cause for cessation of the nurse practitioner-patient relationship.
Dismissal Policy
If you are “dismissed” from the practice it means you can no longer schedule appointments, get medication refills or consider us to be your nurse practitioner/physician/therapist. You have to find a nurse practitioner/physician/therapist in another practice. Common Reasons for Dismissal: Failure to keep appointments, frequent no-shows: Noncompliance, which means you have failed to follow nurse practitioner/physician/therapist instructions about an important health issue; Abusive (verbal or physical) to staff; Failure to pay your bill. We will send a letter to your last known address, notifying you that you are being dismissed. If you have a medical emergency within 30 days of the date of this letter, we will assist you with care options. We will forward a copy of your medical record to your new physician when a release is received.
Laboratory Policy
If may be medially necessary for you nurse practitioner/physician/therapist to request lab or radiologic tests in order to provide the best treatment possible. It is your responsibility, as our patient, to obtain the requested examinations. Our office will assist you in as much as possible, but testing may require you to visit another facility or lab. If you do not obtain these tests within a reasonable time, your nurse practitioner/physician/therapist reserves the right to refuse to refill or prescribe further medications until tests are completed. Urine drug screens (UDS) are performed on patients when necessary. All new patient and patients who are prescribed controlled medication will have an initial urine drug screen and will be subject to monthly UDS after. Any changes that may result from the UDS will be the responsibility of the patient if not covered by the insurance company.
If you would like a copy of the Patient Health and Privacy Information (HIPPA), please request a copy or sign below that you have been informed of the Privacy and confidentiality of your records and information.
Please indicate your agreement to the terms of this policy by signing below: