DR. Frank Scot Elliott, M.D. Psychiatrist, PLLC Green Valley Psychiatric Associates 1090 Wigwam Pkwy #100 Henderson, NV 89074 (702) 454-0201 CONSENT FOR CARE AND ACKNOWLEDGMENT OF POLICES 1. Services provided by Dr. Elliott MEDICATION MANAGEMENT. Dr. Elliott s goal is to minimize the number and dosages of medications needed to maintain safety and stability. Dr. Elliott will work collaboratively with you, to find the best medication regimen to meet your needs. Whenever possible, Dr. Elliott will incorporate your medication preferences into your care plan, as long as it is safe and medically sound to do so. However, what patients want is not always what they need, or the safest, most effective approach to care. In those cases, Dr. Elliott will offer medication that is best for you even if it is not what you prefer. Ultimately, you must provide consent for any medications you take, so the choice to accept Dr. Elliott s recommendations always remains with you. If an agreement cannot be reached, Dr. Elliott will offer a list of other Psychiatrists in the area to whom you can transfer your care. PSYCHOTHERAPY. Most patients will benefit from psychotherapy as part of a complete treatment plan. Dr. Elliott will be able to provide psychotherapy to a limited number of patients on a case by case basis. If Dr. Elliott is unable to provide the psychotherapy that you need, he will give you a list of providers who may be able to better accommodate those needs. As with any part of your treatment, you must consent to psychotherapy, so you are free to decline. CYCLE OF CARE. The typical cycle of care is as follows: 1) Initial visit to obtain history, determine diagnosis, formulate preliminary treatment plan, and begin initial treatment; 2) Follow up approximately every 1-2 months to induce remission of symptoms; 3) Once symptoms are in remission, and treatment goals are reached, medications will be tapered (if possible) to minimum required to maintain treatment goals; 4) Follow up less frequently until long term stability is demonstrated; 5) Once long term stability is established, care may be transferred back to your primary care provider who can provide medication refills as long as you are stable. If your care seems too complex for transfer back to a primary care provider, or if you prefer to continue specialty care, Dr. Elliott may recommend indefinite follow up with him. Page 1 of 5
NON-PSYCHIATRIC MEDICATIONS. Dr. Elliott will work with your other doctors to minimize conflict between psychotropic medications and those you take for your other medical problems. In order to avoid conflicts with your medical care outside Psychiatry, Dr. Elliott does not prescribe non-psychiatric medications (including erectile dysfunction medications). You will need to continue to get those medications from your other doctors. CONTROLLED SUSTANCES. Dr. Elliott does not prescribe controlled substances for long term use. Medications like Valium, Xanax, Klonopin, etc. are never meant to be taken long term. They work on the same receptor systems in the brain as alcohol, which is why they can be used to prevent withdrawal symptoms during detox programs. There is a near epidemic of over prescribing these medications, which leaves many patients struggling through their lives intoxicated on prescription medications. Chronic use of these medications can lead to mood instability and functional problems that cannot be treated effectively with other medications, similar to those seen with alcohol and illicit drug use. Consequently, Dr. Elliott will make every effort to replace addictive medications with nonaddictive alternatives, which will be safer and more effective for long term use. STIMULANTS. There is an epidemic of stimulant (e.g., Adderall, Ritalin, Concerta, etc.) overuse, as well. Prescriptions for these addictive medications are growing at exponential rates. There is a perception that these medications are harmless general mood and performance enhancers, whether or not a person has Attention Deficit/Hyperactivity Disorder (ADHD). These are serious medications that should only be used for patients with ADHD confirmed through specific diagnostic procedures. Stimulants can increase heart rate and blood pressure, and there is growing evidence that long term use of stimulants in adults will increase risks of heart disease and stroke. Consequently, Dr. Elliott does not prescribe addictive stimulants, or treat ADHD. DRIVER S LICENSES. In accordance with standard practice in Psychiatry, Dr. Elliott does not revoke patients driver s licenses, nor does he restore licenses revoked by other doctors. If your driver s license has been revoked by another doctor, you will need to return to that doctor or your primary care provider to have it restored. Family Medical Leave Act (FMLA). Dr. Elliott does not do FMLA or disability paperwork. However, you are free to request copies of your medical record to submit to your employer if you choose. Dr. Elliott is set up to do, and has a great deal of experience with assessments for VA claims and addenda. Page 2 of 5
2. Payment All visits are paid at the time of the visit. We accept cash, check, and all major credit or debit cards (except American Express or Discover) at the time of the appointment. Balances that remain unpaid may be sent to collections after 90 days. Fee schedule: Initial Visit 60min (45min visit/15min documentation) $300 Medication Follow up 20min (15min visit/5min documentation) $100 Telephone Consultation 0-5min no fee; 5-10min $30; 10-15min $60; > 15min $100 Standard Psychotherapy 60min (45min visit/15min documentation) $250 Prolonged Psychotherapy 90min (75min visit/15min documentation) $350 Fees may be adjusted annually on May 1 st. 3. Insurance Dr. Elliott is in the process of enrolling with many different insurance companies. Acceptance of insurance will begin as soon as each carrier completes enrollment. See Currently Accepted Health Care Plans at the following website https://frankelliottcfps.wordpress.com/insurance/. If you do not see your plan listed, then Dr. Elliott is not yet connected with your insurance provider, so he must be considered an out-of-network provider for your insurance company. If your plan is not listed as Currently Accepted, we accept cash, check, and credit or debit cards (except American Express or Discover) at the time of the appointment. We do not accept other insurances, nor do we bill. Patients are responsible for payment of services rendered, at or before the time of service. If your plan is not listed as Currently Accepted, an out-of-network provider receipt of services can be provided for submission to your insurance company, for possible reimbursement. Patients who desire insurance reimbursement are strongly advised to discuss this with their insurance company in advance and understand the parameters of payment for out-of-network providers, deductible and whether pre-authorization is required. Page 3 of 5
4. Medical Records CONFIDENTIALITY. In accordance with the Health Insurance Portability and Accountability Act (HIPAA), your interactions with Dr. Elliott cannot be revealed to anyone unless you provide written approval. That means Dr. Elliott cannot discuss your case with anyone but you, on the phone, in writing, or in person without your written consent. Exceptions to this level of doctor-patient confidentiality include threats to yourself or others. By law, Psychiatrists are required to protect patients who are deemed a threat to themselves, or protect others against whom patients convey credible threats. In addition, reports of abuse of children or others unable to care for themselves will require some action. Confidentiality laws do not apply in these cases. In rare instances, court orders may require exceptions to protection of privileged communications with a Psychiatrist. ELECTRONIC MEDICAL RECORD. In compliance with Federal mandates (American Recovery and Reimbursement Act of 2009), Dr. Elliott uses an electronic medical record system. No paper record will be generated or kept on the premises. All records are stored in a highly secured data storage facility maintained by the electronic medical record company. Hard copies of records may be obtained by submitting a signed Request for Release of Medical Information form. According to HIPAA, Psychiatrists have the right to decline their patients requests for medical records if they feel disclosure of these records might be damaging to the patient. It is extremely rare for Dr. Elliott to decline requests for records, but he reserves the right to do so if necessary. 5. Hours of Operation OFFICE HOURS. Frank Scot Elliott, Psychiatrist, PLLC (FSEP) is an outpatient clinic and does not provide emergency or after hours care. Regular business hours are 8 AM to 4 PM, Monday through Friday, and we are closed for most national holidays. If you are in need of emergent care outside regular business hours, please have someone drive you to the nearest hospital emergency room or call 911 for ambulance transport. If Dr. Elliott is out of town, you may contact your primary care doctor for simple medication needs. TELEPHONE. The phone number for FSEP is 702-454-0201. This phone line is for routine scheduling and medical questions, and is not intended for emergent issues. If you have an emergency please either call the National Crisis Hotline at 800-273-8255 or call 911 for emergency medical services. For routine issues, please leave a voicemail as instructed. During regular business hours, Dr. Elliott will respond to voicemails once in the morning and once in the afternoon. Voicemails left after regular business hours will not be retrieved until the next business day. If your needs cannot wait within these constraints, please seek care at the nearest hospital emergency room or urgent care center. Page 4 of 5
6. Attendance NO SHOWS. If you cannot keep your appointment, please call to reschedule at least 24 hours in advance. Missing your appointment or rescheduling your appointment less than 24 hours in advance may result in a charge of the regular fee for that missed appointment. If you miss your appointment, you will be contacted with a reminder about the missed appointment and a request to reschedule. If we do not hear from you with within 90 days, we will assume that you have terminated care, and your case will be inactivated. Accumulation of 3 unexcused no-shows may result in termination of care. LATE ARRIVALS. For a 60min appointment, you are considered late if you arrive 30min after your scheduled time. For a 20min appointment, you are considered late if you arrive 10min after your scheduled time. You may be charged the regular fee for that appointment, and will need to reschedule for another day. CASE INACTIVATION. Unless you have been scheduled for prolonged intervals between follow-ups by Dr. Elliott, your case will be inactivated if you have not been seen for more than 6 months. If you wish to resume care, you will need to schedule another 60min initial visit to allow for assessment of changes in your case. I acknowledge that I have read the policies contained in this document, I understand and agree to abide by these policies. I voluntarily consent to proceed with treatment. Signature and Today s Date Please Print Your Name Page 5 of 5