We welcome you to CAROLINA PARTNERS IN MENTAL HEALTHCARE, PLLC We prepared the following information so that you may have a clear understanding of our policies and procedures concerning fees, insurance, and confidentiality.
Referrals: Carolina Partners is a group practice. You may be referred within the group to an appropriate health care provider according to your needs.
Fee Schedule: The Clinician’s fee will vary depending on the service rendered, the specific provider involved and the terms of particular insurance plans.
* Prior authorization and claims for four Nurse Practitioners (Ms. Bruce, Dr. Hartsell, Ms. Leif, and Ms. Sumner) may be filed under the name of Dr. Yvonne Monroe. Claims for eleven Nurse Practitioners (Ms. Ashton, Mr. J Cassidy, Ms. R Cassidy, Ms. Corbett, Ms. Fayhee, Ms. Gonzales, Mr. Jeffrey, Ms. Leogrande, Ms. Lutzow, Mr. Odom, and Ms. Vicario) may be filed under the name of Dr. James Smith, III. Claims for one Nurse Practitioners (Ms. Keiser) may be filed under the name of Dr. Gregory Helton. Claims for one Nurse Practitioner (Ms. Karandikar) may be filed under the name of Dr. Sandeep Vaishnavi. Claims for one Nurse Practitioner (Mr. Russo) may be filed under the name of Dr. Ralph Jones. Claims for one Nurse Practitioner (Ms. Shepherd) may be filed under the name of Dr. Deborah Payne. Claims for one Nurse Practitioner (Ms. Angelelli) may be filed under the name of Dr. An’Drea Taylor. Claims for one Nurse Practitioner (Ms. Tyma) may be filed under the name of Dr. Vida Robertson.
Record Copy Fee: To cover the costs incurred in searching, handling and copying medical records a fee for each request shall be seventy-five cents per page for the first 25 pages, fifty cents per page for pages 26 through 100 and twenty-five cents for each page in excess of 100 pages and a minimum fee of up to ten dollars, inclusive of copying costs, for mailing medical records for the patient or the patient’s designated representative. If requested by the patient or the patient’s designated representative, nothing herein shall limit a reasonable professional fee charged by a physician for the review and preparation of a narrative summary of the patient’s medical record. This section shall only apply with respect to liability claims for personal injury and claims for social security disability, except that charges for medical records and reports related to claims under Article 1 of Chapter 97 of the General Statues shall be governed by the fees established by the North Carolina Industrial Commission pursuant to G.S. 97-26.1. This section shall not apply to Department of Health and Human Services Disability Determination Services requests for copies of medical records made on behalf of an applicant for Social Security or Supplemental Security Income disability (1993, c. 529, s. 4.3; 1993 (Reg. Sess. 1994), c. 69, s. 5.5; 1995 (Reg. Sess., 1996), c. 742, s. 36;1997 -443, ss. 11.3,11A.118(b).)
Telephone Calls: Carolina Partners charges $15 to obtain the prior authorization required by your pharmacy benefits for certain medications. This is a 15-20 minute process. Clients in psychotherapy may occasionally have the need for crisis intervention by telephone. Telephone charges are based upon the provider’s standard fee per 45 minutes and prorated per minute. There is no charge for calls under 5 minutes concerning side effects of medications that you have been prescribed by a Carolina Partners provider. However, if the medication call involves phoning in or otherwise reissuing a prescription, you will be charged. After 5 PM and after noon on Fridays until Monday at 8 AM, there may be a $25.00 charge for calling in a refill or writing a prescription to be picked up. The on-call clinician will only provide enough medication through your regular clinician’s next business day.
Appointments: No one is guaranteed an appointment with a clinician at Carolina Partners but we accept most insurance and managed care plans and will do our best to accommodate you. If you are unable to keep an appointment, please notify our office immediately. This time is reserved exclusively for you. If an appointment is cancelled or missed without 24 business hours notice, you will be billed for the session. Some appointments are scheduled over the phone, and not in person. Our Assistant may call with your appointment date and time as a reminder, and may leave a message on your answering machine, or with a responsible party in your household, unless you specifically request us not to do so. With or without an answering machine or other party telephone reminder, you are still responsible for cancelling with 24 hours notice, or you will be billed for the session as above.
Payment: As a courtesy to you, Carolina Partners will normally accept assignment of any insurance benefits you may have and file health care claims directly to your insurance company. However, payment of all applicable copays and deductibles (or any other amount not covered by your primary insurer) is required at the time services are rendered. Payment may be made by cash, check, credit or debit card. Every client is asked to sign a “Financial Acceptance” agreement that is appended to this document. If you are unable to pay your obligation at the time of service, we may ask you to authorize Carolina Partners to charge your credit card for any balance due more than 60 days old. Please note that we will not charge your credit card if there is no balance due more than 60 days old. There will be a $25 service charge for returned checks. Notwithstanding the former, Carolina Partners reserves the right to demand full payment for services rendered at the time of service. If you are covered by more than one insurance company and we receive prompt payment from your primary insurer, Carolina Partners will normally file claims to your secondary insurer as a courtesy to you. However, pending payment by your primary insurer, you may be asked to make payment at the time services are rendered of any amounts covered by your secondary insurer.
Carolina Partners will not be able to file claims to your insurance company unless you provide us with accurate and complete information about your insurance plan. Accordingly, we ask you to review your policy carefully and to be aware of any limitations on your benefits. You must also promptly inform us of any changes in your insurance coverage or we will not be able to file your claims. Similarly, many insurance companies are now managing their mental health benefits. This means you must consult your insurance booklet to see if your insurance must approve sessions before they occur. If this approval is not obtained, your insurance will not cover the sessions. If you are not sure, please ask Carolina Partners to help you with these prior authorizations.
** Please note that you are ultimately responsible for all charges incurred for your treatment or the treatment of those for whom you are responsible. If for any reason your insurance company, or other third party payer (such as a divorced spouse or lawyer), does not promptly reimburse Carolina Partners for services rendered, you will be responsible for those charges (subject to any applicable law or the terms of any contract we may have with your insurer).
Statements: Unless you specifically request not to receive a statement, you will be billed on a monthly basis for any past due balance you may owe. Payment of all services is expected within 30 days of the date they were rendered. Processing past due accounts is expensive and Carolina Partners reserves the right to add a finance charge to any past due balance accrued. This charge shall not exceed 1 1/2% per month (an annual percentage rate of 18%). Accounts with balances more than three months old may be referred to a collection agency for processing.
Confidentiality: Any confidential information you disclose to us during treatment, or any other confidential information we obtain while attending to you professionally, shall be held in confidence unless you permit us to disclose such information or where we are required to disclose such information by law.
By signing this contract, you are agreeing to the disclosure of confidential information where such disclosure is necessary to obtain certification, authorization, or payment for your treatment, or where we are required to disclose information by the terms of our contract with your insurer or managed care company. For example, in order for your insurance company to cover your treatment, we may be required to periodically communicate details of your condition and treatment with them or with your managed care case manager. You are also expressly authorizing your provider to pursue appeals and grievances with insurers or managed care companies when those appeals are necessary to obtain payment for one of your insurance claims or when your provider believes an appeal of denial of care by your insurer is appropriate or necessary.
By signing this contract, you are agreeing to the disclosure of confidential information to other physicians or therapists familiar with your case, where your provider decides it is clinically necessary or appropriate to do so. For example, if a physician or psychotherapist referred you to us for evaluation and treatment, your Carolina Partners provider may communicate with that professional about your condition and treatment. Please tell us in advance if you want certain information withheld. Similarly, if we refer you to another physician or therapist within Carolina Partners for treatment, that provider will have access to your records and may communicate with your prior provider(s).
Forensic Matters: Carolina Partners may be required by law to disclose confidential information in certain cases. The following are examples:
1. If we assess that you are a clear and imminent danger to yourself or another person, appropriate others may be notified to prevent that occurrence.
2. If there is reason to suspect that child or elder abuse has occurred, the law requires that it be reported to the proper authorities.
3. In a legal proceeding, the Judge may order disclosure of information he feels would be necessary for the proper administration of justice.
Court Appearances: In certain cases, a Carolina Partners clinician may be willing to act as an Expert Witness in a court action involving a client. If you wish to engage the services of a clinician as an Expert Witness, you must read and sign a Carolina Partners Expert Witness Agreement that binds you to payment for the clinician’s time in preparing for court, appearing in court, preparing reports, communicating with attorneys, etc. Please discuss the possibility of court appearances with your doctor or therapist as far in advance as possible.
In the event that a Carolina Partners clinician is subpoenaed to appear in a court action involving the care that was delivered to you or to a family member, you will be charged that clinician’s standard fee for court appearances, etc. even in the absence of a signed Expert Witness agreement. Even if the subpoena is not issued by your attorney, but rather by an adverse party, you will be charged for and expected to pay the clinician’s fees for these services.
On Call: Several providers share a rotating on-call schedule, starting Fridays at noon until Monday morning. Each office is open for scheduled appointments only after noon on Fridays. You may leave a phone message which will be picked up on Monday. Please call the number of your office to obtain the name and number of the on-call clinician. If you think you or your family member may require hospitalization, please call the Respond Service at Holly Hill / Charter Hospital at 1-800-447-1800 for a free consultation 24 hours a day.
For emergencies call 911.
Grievances: Anyone who has a grievance about any aspect of the services received from Carolina Partners may submit a grievance. You may call us with your concerns or submit them in writing. The addresses for complaints about clinical services are:Carolina Partners in Mental HealthCare, PLLC
Attn: Customer Service Dept.
1502 W NC Hwy 54, Suite 103
Durham, NC 27707
Our Customer Service e-mail is email@example.com and the phone number is 919-792-3938.