PSYCHIATRIC SERVICES INFORMED CONSENT
I _________________, (Parent/Legal Guardian of ____________) do voluntarily consent to care and treatment by Nancy Nicole Mason, Psychiatric Mental Health Nurse Practitioner- Board Certified and/or Roxian Hancock Odom, Psychiatric Mental Health Nurse Practitioner- Board Certified.
GENERAL
I understand than no guarantees are being made to me as to the results of evaluation or treatment.
I am aware that I am an active participant in this endeavor, and that I share the responsibility for treatment by providing all accurate information about my (or my child’s) history.
I understand that our work will be kept confidential with the exception of disclosures required by law and when necessary in connection with my care. In particular, I am aware that, although my Psychiatric Nurse Practitioner is a clinically independent practitioner, consultations with associates are at times clinically advisable and my signature below gives my PMHNP permission to do that. The associates also provide emergency coverage for each other when one is out of the office, and I understand that an associate providing coverage for my PMHNP may need access to relevant information to provide the best interim care possible. My PMHNP works collaboratively with a collaborating physician as well to ensure that every effort is being made to best support my needs.
I authorize the release of any information necessary to help get preauthorization for medications.
I understand that if I arrive more than 10 minutes late for my appointment, I may have to wait to be seen as a walk-in.
I am aware that all balances and fees must be paid prior to my appointment. Please arrive a few minutes early for your appointment to check in.
I am aware that my PMHNP, or her support staff, will make every effort to return calls within 72 business hours.
I understand that an email and text reminder for appointments and other communication is automatically provided if I offer my email address and phone number.
I understand that I will be charged additional fees for the following services:
MEDICATION RULES
I understand that my PMHNP participates in the Prescription Monitoring Program and, by law, may access information about me and/or report information about me, as applicable.
I understand that my PMHNP participates in systems cooperation with other community entities- to include but not limited to- other providers/health systems/laboratories/ pharmacies, etc., and may access information about me, as applicable to my care.
I understand that my PMHNP must be informed if I am receiving or plan to receive, psychiatric medication management from another provider. My PMHNP is willing to coordinate a transition to a new provider if/when I choose to make a change.
Refill requests due to missed appointment(s) will be filled at the PMHNPs discretion. This includes possible tapering doses, no refills, limited quantity (which can affect payment from insurance), and/or modified doses.
I understand that it may take up to 48 business hours for a refill request to be completed, and that there is no guarantee that my PMHNP will approve the request.
Controlled substances may require a hard copy prescription, will not be authorized to fill early, and will not be replaced if lost and/or stolen.
Please plan ahead and schedule an appointment prior to running out of your medication.
I understand that if I have not attended an appointment for more than 6 months, my medications will not be refilled. I will be scheduled for a new intake at the discretion of my PMHNP.
If I am terminated for any reason from mindFULL, a 30-day supply of most medications will be provided to me at my PMHNP’s discretion.
In accordance with Mississippi State Law, I will not be prescribed benzodiazepines in conjunction with opioids.
I understand that I may be required to have a urine drug screen, at my own cost, if deemed necessary by my PMHNP.
EMERGENCY POLICY
If you are experiencing a psychiatric emergency, a life-threatening emergency, and/or medication side effects causing shortness of breath, heart problems, a rash, and/or other life-threatening concerns, CALL 911 or go to your nearest emergency room. While the PMHNP, or her support staff, may be able to contact your medical provider regarding medication emergencies during established business hours, this is not guaranteed outside of normal business hours. Medication management is managed during regular business hours, when the PMHNP is in the office. Phone calls will be returned within 72 business hours.
PATIENT RIGHTS/DISCHARGE
Non-voluntary discharge from treatment- A patient may be terminated via a non-voluntary discharge letter if:
A patient may choose to terminate treatment at any time of their own accord, and a 30-day supply of most medications will be provided.
mindFULL, P.A. has provided me with a copy of
____ I have received these copies via email. I am aware that these policies and this form are located on mindFULL’s webpage www.mindfullbpc.com. I have been offered to receive a hard copy to review and/or keep for my own records. I have been offered to have a staff member read these policies and this form to me.
____ I have the right to revoke this consent in writing and terminate my Psychiatric Nurse Practitioner at any time.
____ I have read and understand the information on this sheet. My signature below indicates my informed consent to care and treatment by Nancy Nicole Mason, Psychiatric Mental Health Nurse Practitioner- Board Certified and/or Roxian Hancock Odom, Psychiatric Mental Health Nurse Practitioner- Board Certified.
It is helpful that we make contact with your Primary Care Physician and other providers if applicable to coordinate you care. If you object to this, please indicate below and this will be discussed in you first session.
______________________________________________
Printed legal name of individual receiving treatment
______________________________________________
Printed legal name of parent/legal guardian consenting to treatment
______________________________________________ ______________
Signature of individual or parent/legal guardian Date
GENERAL
I understand than no guarantees are being made to me as to the results of evaluation or treatment.
I am aware that I am an active participant in this endeavor, and that I share the responsibility for treatment by providing all accurate information about my (or my child’s) history.
I understand that our work will be kept confidential with the exception of disclosures required by law and when necessary in connection with my care. In particular, I am aware that, although my Psychiatric Nurse Practitioner is a clinically independent practitioner, consultations with associates are at times clinically advisable and my signature below gives my PMHNP permission to do that. The associates also provide emergency coverage for each other when one is out of the office, and I understand that an associate providing coverage for my PMHNP may need access to relevant information to provide the best interim care possible. My PMHNP works collaboratively with a collaborating physician as well to ensure that every effort is being made to best support my needs.
I authorize the release of any information necessary to help get preauthorization for medications.
I understand that if I arrive more than 10 minutes late for my appointment, I may have to wait to be seen as a walk-in.
I am aware that all balances and fees must be paid prior to my appointment. Please arrive a few minutes early for your appointment to check in.
I am aware that my PMHNP, or her support staff, will make every effort to return calls within 72 business hours.
I understand that an email and text reminder for appointments and other communication is automatically provided if I offer my email address and phone number.
I understand that I will be charged additional fees for the following services:
- Professional Forms which include, but are not limited to, forms for employment, school, return-to-work, disability, retirement, legal action, etc. These forms may take up to 10 business days to complete from the time of the request. Fees are rated based off of the type of form and the time it takes to complete the form.
- Letter(s) which include, but are not limited to, letters pertaining to insurance, employment, return-to-work status, school, disability, retirement, and legal action. These letters may take up to 10 business days to complete from the time of the request. Fees are rated based off of the type of letter and the time it takes to complete the letter.
- Medical Records are provided at a $10.00 flat rate, and an additional $0.50 for the first 75 pages and $0.25 after. Medical records can take up to 10 business days to complete from the time of the request. All requests for copies of medical records must be received in writing, dated, signed, and include a reasonable description of the records sought.
- Subpoena for Witness: If my PMHNP is subpoenaed for court, the fee is $450 per hour, plus additional fees.
MEDICATION RULES
I understand that my PMHNP participates in the Prescription Monitoring Program and, by law, may access information about me and/or report information about me, as applicable.
I understand that my PMHNP participates in systems cooperation with other community entities- to include but not limited to- other providers/health systems/laboratories/ pharmacies, etc., and may access information about me, as applicable to my care.
I understand that my PMHNP must be informed if I am receiving or plan to receive, psychiatric medication management from another provider. My PMHNP is willing to coordinate a transition to a new provider if/when I choose to make a change.
Refill requests due to missed appointment(s) will be filled at the PMHNPs discretion. This includes possible tapering doses, no refills, limited quantity (which can affect payment from insurance), and/or modified doses.
I understand that it may take up to 48 business hours for a refill request to be completed, and that there is no guarantee that my PMHNP will approve the request.
Controlled substances may require a hard copy prescription, will not be authorized to fill early, and will not be replaced if lost and/or stolen.
Please plan ahead and schedule an appointment prior to running out of your medication.
I understand that if I have not attended an appointment for more than 6 months, my medications will not be refilled. I will be scheduled for a new intake at the discretion of my PMHNP.
If I am terminated for any reason from mindFULL, a 30-day supply of most medications will be provided to me at my PMHNP’s discretion.
In accordance with Mississippi State Law, I will not be prescribed benzodiazepines in conjunction with opioids.
I understand that I may be required to have a urine drug screen, at my own cost, if deemed necessary by my PMHNP.
EMERGENCY POLICY
If you are experiencing a psychiatric emergency, a life-threatening emergency, and/or medication side effects causing shortness of breath, heart problems, a rash, and/or other life-threatening concerns, CALL 911 or go to your nearest emergency room. While the PMHNP, or her support staff, may be able to contact your medical provider regarding medication emergencies during established business hours, this is not guaranteed outside of normal business hours. Medication management is managed during regular business hours, when the PMHNP is in the office. Phone calls will be returned within 72 business hours.
PATIENT RIGHTS/DISCHARGE
Non-voluntary discharge from treatment- A patient may be terminated via a non-voluntary discharge letter if:
- Patient exhibits physical violence, physical or emotional intimidation, and/or verbal abuse of any kind
- Patient and/or family members carry weapons or engage in illegal acts of any kind
- Patient and/or family members are abusive in phone correspondence
- Patient refuses to comply with stipulated clinic rules
- Patient refuses to comply with treatment plans/recommendations
- Patient does not make payments and/or resolve declined payments in a timely manner
- Patient repeatedly cancels, late cancels, or no shows for appointments
A patient may choose to terminate treatment at any time of their own accord, and a 30-day supply of most medications will be provided.
mindFULL, P.A. has provided me with a copy of
- Notice of Privacy Practices
- Patient Rights
- Confidentiality and Contraband Statement
____ I have received these copies via email. I am aware that these policies and this form are located on mindFULL’s webpage www.mindfullbpc.com. I have been offered to receive a hard copy to review and/or keep for my own records. I have been offered to have a staff member read these policies and this form to me.
____ I have the right to revoke this consent in writing and terminate my Psychiatric Nurse Practitioner at any time.
____ I have read and understand the information on this sheet. My signature below indicates my informed consent to care and treatment by Nancy Nicole Mason, Psychiatric Mental Health Nurse Practitioner- Board Certified and/or Roxian Hancock Odom, Psychiatric Mental Health Nurse Practitioner- Board Certified.
It is helpful that we make contact with your Primary Care Physician and other providers if applicable to coordinate you care. If you object to this, please indicate below and this will be discussed in you first session.
- Yes, I consent to sharing information with my other providers.
- No, do not share information at this time.
______________________________________________
Printed legal name of individual receiving treatment
______________________________________________
Printed legal name of parent/legal guardian consenting to treatment
______________________________________________ ______________
Signature of individual or parent/legal guardian Date
