Consent

IN CASE OF EMERGENCY

• If experiencing a life-threatening EMERGENCY, please dial 9-1-1

• Central Arizona Crisis Line: (602) 222-9444 or (800) 631-1314

• National Suicide Prevention Lifeline: (800) 273-8255 (TALK) or dial 9-8-8

• Teen Lifeline (www.teenlifeline.org): (602) 248-8336 (TEEN)

• Domestic Violence Hotline (800) 799-SAFE (7233), TTY (800) 787-3224, or Text “START” to 88788

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CLINIC POLICY

• Patients are financially responsible for any outstanding fees not covered by insurance. Hence, we REQUIRE a form of payment (credit card, debit card) be kept on file.

• We DO NOT provide primary substance abuse treatment. Since our providers are not substance abuse or addiction specialists, we recommend person go to an agency who specializes is substance abuse/addiction treatment or detox for more customized care.

• For medication management, we DO NOT accept patients who are LESS THAN 30-days removed from substance abuse rehab (6-months for very addictive drugs).

• For medication management service, we DO NOT accept patients who are actively receiving Medication-Assisted Treatment (MAT) for substance abuse.

• We DO NOT have a contract with Workers Comp agencies, hence patient will be financially responsible for all cost.

• We DO NOT have a contract with AHCCCS, hence AHCCCS patient will be financially responsible for all cost.

• Prior to completing any DISABILITY PAPERWORK, patient must understand the following:

  • Person must have AT LEAST three (3) appointments with the SAME provider for ninety (90) days.

  • Our providers DO NOT complete long-term disability paperwork.

  • Our providers DO NOT complete SMI paperwork.

• For MEDICAL RECORDS REQUESTS, the following applies:

  • Anticipate at least SEVEN (7) BUSINESS DAYS to process.

  • Release of Information (ROI) must be in place at time of request.

  • There is NO COST to process and send medical records to another provider or clinic to coordinate clinical care. For all other individuals or entities, there is a FEE to process, collect, and send medical and billing records.

• Our providers DO NOT participate in court and legal proceedings, such as but not limited to, custody cases, professional board hearings, nor workman comp cases. In event appearance and participation of the provider is required, the associated fee is defined within our policies and procedures. The patient is financially responsible for ALL legal-specific fees incurred.

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NO SHOW/LATE CANCELLATION POLICY

• We impose an automatic $150 fee for No Shows/Late Cancellations. (This fee is subject to change without notice.)

• Fees are due by invoice or on next scheduled appointment.

• LATE CANCELLATION is described as:

  • Cancellation under 24-hours prior to scheduled appointment​ (Monday appts must be cancelled by Friday 12pm). Cancellation must be confirmed by staff to be valid.

  • 15-minutes LATE to an INTAKE (patient portal must be completed by time of scheduled appointment)

  • 8-minutes LATE to a PSYCHIATRIC (MEDICATION) FOLLOW-UP

  • 15-minutes LATE to a THERAPY FOLLOW-UP

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MEDICATION REFILL POLICY

• All medication refill requests or questions must be emailed to REFILL@LHPSYCH.COM.

• Medication refill request takes SEVEN (7) BUSINESS DAYS to process.

• We DO NOT accept medication refill request by phone.

• We DO NOT check emails on the weekends. Hence, refill requests received on the weekend will be reviewed on next available business day.

• NO SAME DAY REFILLS, without exception.

• Refill of DEA-regulated controlled medications may be restrictive and require more frequent appts and drug testing to monitor for risk of chemical and psychological dependency