PROOF OF ADHD TESTING IS REQUIRED FOR ADULTS REQUESTINGSTIMULANTS (ADDERALL, RITALIN, VYVANSE, ETC).THIS OFFICE DOES NOT PRESCRIBE BENZODIAZEPINES. (BENZOS- ATIVAN, XANAX, ETC ETC).
Social Media / Medications Policy
Social Media: We will not “Friend” or “Follow” anyone that is a patient nor are they allowed to contact us on Social Media about patient care on our Business pages. By signing this document I acknowledge that any comment made on a public forum to include Social Media pages, Yelp, Google, or any other public forum is publicly available, therefore posting a review you are consenting to identify yourself as a patient at Uncharted Territory Mental Health PLLC and we are not liable for breach of confidentiality.
Medications: We only accept refill requests from current patients, refill requests will be reviewed on a case-by-case basis, clients should call or use the portal with a minimum of five days' notice unless your appointment has just been completed. If your request is less than the minimum time frame, there will be a $25 dollar urgent prescription fee that is not covered by insurance. Medications will only be filled until the next appointment. NO Prescriptions will be written at the initial appointment.
Controlled Substance Policy
PROOF OF ADHD TESTING IS REQUIRED FOR ADULTS REQUESTING STIMULANTS (ADDERALL, RITALIN, VYVANSE, ETC).
THIS OFFICE DOES NOT PRESCRIBE BENZODIAZEPINES.
Our individual providers follow maximum dosing guidelines for controlled medications used to treat anxiety, ADHD, and insomnia
Patients being prescribed controlled substances agree to the possibility of being required to do random toxicology screens in order to get prescriptions of controlled substances.
Our prescribers may request medical records from recent prescribers before prescribing any psychiatric medications
Our prescribers do not prescribe pain medications, muscle relaxants, or medical cannabis
If you are taking narcotic pain medications, medical cannabis, or are abusing drugs or alcohol our providers may not prescribe controlled substances to you
No controlled substance medications will be prescribed without an in-person appointment with a prescriber.
Taking controlled substances other than how it is prescribed is grounds for termination of care
Positive toxicology screens are grounds for termination of care.
No Show & Cancellation Policy
If you need to cancel an appointment, please contact us at 888-839-6474, email; email@example.com, cancel online or message us on the portal during regular clinic hours(note that this does NOT include Saturday or Sunday), at least 24 hours before your scheduled appointment to reschedule to a better time.
The 24-hour period does not include Saturdays or Sundays, so Monday appointments would incur a missed appointment charge if a call or message was sent on Saturday or Sunday to cancel a
Any No Show or Cancellation by the client not in the allotted time frame will be charged a $50 dollar No Show or Cancellation fee.
Please be respectful of other patients’ appointments and arrive at least 10 minutes prior to your appointment time. We ask that you verify your method of communication and download any necessary apps, make sure you can access the app and be ready for your appointment at least 10 minutes prior to your appointment. If you are having technical difficulties it is your responsibility to contact the office to resolve these issues PRIOR to your appointment. Failure to keep your scheduled appointment will result in the full fee being charged to the credit card on file for both initial visits and follow-up visits unless you cancel at least twenty-four (24) hours prior to the appointment time.
A balance is considered “overdue” when the client has not made a payment on the amount not covered by insurance within 2 billing cycles (60 days) since the appointment.
Clients with overdue balances exceeding $300 will be required to comply with one of the three options listed below:
Pay down their balance before being seen for an appointment with a provider
Pay upfront for their appointment before being seen by a provider
Reschedule the appointment until their balance is reduced to under $300.
If a client has a balance that has been outstanding for 90+ days, regardless of the amount, they must pay for any appointment going forward upfront and in full, their balance will also be forwarded to a collection agency.
Payments and Insurance
Payment is due at the time services are rendered. We will require a credit card to be on file. Your payment may consist of an insurance deductible, a co-payment, co-insurance, or full payment for uninsured patients or those services not covered by an insurance plan.
Please be prepared to show your insurance card at every visit. Keeping your records up to date helps us expedite referrals and authorizations necessary for your care and ensures we have the information needed to bill your insurance company accurately and timely.
Medication changes or refills need an in-person or telehealth appointment at the clinic. No medication changes or refills will be made during phone calls.
Phone calls longer than 10 minutes will be billed at $40/10minutes.
Uncharted Territory reserves the right to terminate patients from care when a patient misses two or more scheduled appointments without giving a 24-hour cancellation notice within a 6- month span.
Missed appointments or cancellations within 24 hours will result in a $50 dollar charge. This charge is not covered by your insurance and will be billed as your responsibility. Clients with two or more unpaid missed appointment fees are subject to termination of care.
At Uncharted Territory, we have the utmost respect for your privacy and confidentiality.
New Patient Intake forms and Insurance information
When you schedule your first appointment at Uncharted Territory you will be provided with intake forms that will need to be received by the clinic at least 3 business days prior to your appointment or your appointment may be canceled. These forms allow our providers the opportunity to prepare for your appointment and our billing and scheduling departments the opportunity to prepare your new patient file prior to your appointment
Requesting Forms or Letters from Your Provider
If you need any forms filled out by your provider or any letter written by your provider, you will need to schedule an appointment with your provider for the completion of these forms and/or letters. You will need to bring these forms to your appointment, mail them or fax them with all patient sections already filled out. For letters, you will need to bring the name and contact information of any person and/or department to send the letter, as well as addresses, emails, and/or fax numbers for sending the letter. There will be a $75 charge for each form up to six pages. This charge is not covered by insurance.
Concerns for Safety
If as a patient, you are deemed a safety concern for self and/or others or are assessed during evaluation to have declined physically and emotionally to the point that self-care is an issue, it is our legal obligation to inform mental health deputies or officials for further action which may include detainment or acute psychiatric hospitalization. In such events as noted above, your confidentiality and your records will be released to officials and the aftercare facility.