MTI PSYCHIATRY INC.

PRACTICE POLICIES

Welcome! Agreement to the following terms and conditions is required for the patient [“you” or “your”] to receive psychiatric services from Dr. Michael T. Ingram, Jr., M.S., M.D. [“provider” or “me” or “I”].  If you do not agree, I will be glad to give you referrals to other providers.

Clinical services

You are providing consent to receive a comprehensive diagnostic assessment.  At the end of the evaluation, we will mutually decide if we will continue treatment together.

If you are in a life threatening medical and/or psychiatric emergency or you are a threat to public safety, you agree to call 911 immediately or go to the nearest emergency room. For non life-threatening inquiries please feel free to reach me anytime between 8am and 8pm by phone, email, or luminello messaging. Please know I will do everything I can to respond as soon as possible. You can expect a response within 48 hours.

Note that I do not have admitting privileges, nor am I affiliated with or on staff at any hospital. Should I deem more intensive services are needed than I can provide, I will do my best to ensure safety and obtain the appropriate level of care, but I cannot provide that care directly and cannot guarantee the receipt or quality of care that others provide.

All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. You are entitled to receive a copy of these records unless I believe that seeing them would be emotionally damaging. If this is the case, I will be happy to provide the records to an appropriate mental health professional of your choice or to prepare an appropriate summary instead. Because client/patient records are professional documents, they can be misinterpreted and can be upsetting. If you wish to see the records, it is best to review them with me so that we can discuss their content.

If you are seeing me for medication management:

• You agree to contact your therapist first (if applicable) for any psychiatric emergency or crisis, unless it is related to medication. If the emergency or crisis is related to medication, you agree to contact me immediately. HOWEVER, if you are experiencing a life threatening medical and/or psychiatric emergency, you agree to dial 911 or go to the nearest emergency room.
• You agree to inform me if you are considering stopping therapy, or have actually stopped
• You agree to see me in person or via telemedicine video conferencing at LEAST once per month for the first three months. After the first three months, you agree to see me in person or via telemedicine video conferencing at LEAST once every three months.

If you are being prescribed a schedule II or schedule III medication:

• You agree to see me in person or via telemedicine video conferencing at LEAST once per month. Schedule II or schedule III medications will not be prescribed unless you are seen.
• NOTE: State law requires that all patients prescribed scheduled medications be seen IN-PERSON AT LEAST once per year.

A LIST OF SCHEDULED MEDICATIONS CAN BE REVIEWED BY VISITING https://www.dea.gov/drug-scheduling

PLEASE NOTE: NO SERVICES WILL BE PROVIDED UNTIL PAYMENT IS MADE IN FULL. NO EXCEPTIONS.

If you are seeing me for psychotherapy ONLY:

• You agree to contact me for any emergency or crisis, unless it is medication related. If the emergency or crisis is related to medication, you agree to contact the provider who is prescribing the medication first. HOWEVER, if you are experiencing a life threatening medical and/or psychiatric emergency, you agree to dial 911 or go to the nearest emergency room.
• You agree to inform me if you are considering stopping therapy, or have actually stopped
• You agree to see me in person or via telemedicine video conferencing as you prefer. There is no follow up requirement if you are seeing me for psychotherapy ONLY.

I reserve the right to STOP or DISCONTINUE prescribing any medication(s) for any of the following reasons at any time:

1. The policies outlined above are violated
2. Based on my professional and clinical judgement, there is a medical or psychiatric contraindication that necessitates stopping or discontinuing any medication(s)
3. Continuing any medication(s) pose(s) a significant risk to your physical or mental health that is not outweighed by potential benefits.
4. Based on my professional and clinical judgement, there is suspicion of abuse or diversion of medications prescribed for you.

Risks and benefits of psychotherapy:

• Psychotherapy has both benefits and risks. Possible risks include the experience of uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events. Potential benefits include a reduction in feelings of distress, better relationships, better problem-solving and coping skills, and resolution of specific problems. Given the nature of psychotherapy, it remains an inexact science and no guarantees can be made regarding the outcome.

Confidentiality

There is no guarantee of confidentiality under the following conditions:* If I suspect you are in imminent danger of harm to self or others, or a child or elderly person is being abused or neglected (as I am a mandated reporter).

• If a court orders a release of information
• If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
• If you pay by credit card, my name will appear on your credit card statement
• If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collections agency or other responsible party
• Between me and my administrative staff
• With your written permission only: between colleagues with whom I consult professionally.
• If you use text messaging or email to contact Dr. Ingram or his Administrative Assistant which is NOT a HIPAA Compliant means of communication
• If you call Dr. Ingram or his Administrative Assistant by phone which is NOT a HIPAA Compliant means of communication

Payment

You agree to pay for services and fees as outlined in the PAYMENT POLICY AGREEMENT section (see below). You are responsible for full payment, whether your insurance company ends up paying partially, or not at all, for services rendered. I do not communicate with insurance companies directly.
  

You are financially responsible for all charges, whether or not:

• Insurance pays for any services
• We decide to proceed with treatment
• Treatment is successful, for which there cannot be any guarantee

COVID-19 STAY-AT-HOME ORDER

Due to the STAY-AT-HOME order issued by California Gov. Newsom, all appointments will be conducted via telemedicine unless alternative arrangements have been made. This will remain until further notice. In the event that Telemedicine is not accessible to you or unavailable to you, please contact Dr. Ingram’s Administrative Assistant, Miranda Alvarado, by calling or texting 949-436-9099 to arrange for in-office visits. For your safety, masks will be required.

PAYMENT POLICY AGREEMENT

Unless other arrangements have been made, the rates above apply.

Thank you for the opportunity to help you meet your mental health goals. This Payment Policy Agreement is designed to help Dr. Ingram provide the most efficient and reasonable health care services. Therefore, it is necessary to have a Payment Policy Agreement stating Dr. Ingram’s requirements for payment for services provided to patients. Dr. Ingram’s services and rates are provided below:

INITIAL DEPOSIT: Beginning January 6th, 2021 a deposit of $100.00 will be required to reserve your initial consultation visit. This deposit will be refunded ONLY IF cancellations are made prior to 72 hours of your scheduled visit. Cancellations made within 72 hours of your initial consultation visit will result in forfeit of the initial deposit. Please note that rescheduling an initial consultation visit will not result in forfeiting of the initial deposit if you keep the appointment. That is, once you reschedule an initial visit you will not be refunded the initial deposit of $100.00 if you decide to cancel the appointment at a later date.

JACKSON HOUSE PATIENTS: If you were admitted to Jackson House Crisis Residential Treatment Facility and evaluated by Dr. Ingram YOU WILL NOT NEED AN INITIAL CONSULTATION VISIT.

Phone Calls, Text Messages, Paper work, and Administrative Work: Beginning January 1st, 2021 all phone calls, text messages, and/or paper work requested outside of your scheduled appointment will be charged at a rate of $5.00/min.

Luminello Messaging: Messaging Dr. Ingram directly via Luminello messaging will remain free of charge. If you have questions that cannot be answered in a quick response, please schedule a follow up visit by phone or telemedicine using the online scheduling tool or by calling/texting Dr. Ingram’s Administrative Assistant, Miranda Alvarado, at 949-436-9099. Requesting a refill and/or simple questions will remain free of charge.

For patients with PPO Insurance Plans: Dr. Ingram is considered an “Out-of-Network” Provider. Some insurance companies will pay for services from “Out-of-Network” Providers, but there is no guarantee that your insurance company will pay for services. You are responsible for paying the total amount billed for each session, regardless of whether your insurance company pays. Dr. Ingram does not accept Medicare or Medi-Cal as forms of payment (Non-Participating Provider).

Furthermore, Dr. Ingram is not responsible for any communication with insurance companies. This includes, but is not limited to, generating insurance claims, disputing reimbursements, or completing prior authorization forms for medications, laboratory studies, or other diagnostic studies recommended by Dr. Ingram. You will be able to generate an insurance claim for yourself through Luminello, Inc., the electronic medical record (EMR) system used by Dr. Ingram. If needed, Luminello has a user- guide to help you generate an insurance claim that you can submit to your insurance company.

There is no guarantee that your insurance company will reimburse you for the services provided by Dr. Ingram. You will be considered a self-pay patient during the entire course of treatment with Dr. Ingram unless Dr. Ingram decides to accept your insurance plan in the future. Payment is due at the time of your scheduled appointment. **No services will be provided until payment is received.**

The rates (prices) listed above will not change for the first 12 months of treatment, which begins on the day of your initial consultation visit and ends exactly 12 months after the day of your initial consultation visit. After the initial 12 months of treatment, rates (prices) for services may increase. You always have the option of discontinuing treatment with Dr. Ingram at any time and he will offer you referrals upon request.

ACCEPTED METHODS OF PAYMENT

• Cash
• Personal Check or Money Order
• Venmo
• Zelle
• Credit Card/Debit Card/HSA Card
• PayPal

NOTE: You will be able to generate your own insurance claim to submit to your insurance company for reimbursement (i.e., “Super Bill”)

What are all the potential Fees I could incur during my treatment with Dr. Ingram?

1. Cancellation/No Show Fee: Not showing up to a scheduled appointment AND/OR canceling an appointment within 48 hours of your scheduled follow up appointment are subject to a $100.00 Cancellation Fee. Repeated “No Shows” and/or last minute cancellations will result in your credit card or debit card being charged for the full rate of the visit.

2. INITIAL DEPOSIT: Beginning January 6th, 2021 a deposit of $100.00 will be required to reserve your initial consultation visit. This deposit will be refunded ONLY IF cancellations are made prior to 72 hours of your scheduled visit. Cancellations made within 72 hours of your initial consultation visit will result in forfeit of the initial deposit. Please note that rescheduling an initial consultation visit will not result in forfeiting of the initial deposit if you keep the appointment. That is, once you reschedule an initial visit you will not be refunded the initial deposit of $100.00 if you decide to cancel the appointment at a later date.