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 “my” or “I” or “we” or “our”]. If you do not agree, I will be glad to give you referrals to other providers.
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 9am and 6pm 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 contents.
IF YOU ARE SEEING ME FOR MEDICATION MANAGEMENT:
IF YOU ARE BEING PRESCRIBED A SCHEDULE I, II, III, IV, AND/OR V MEDICATION:
If using Telepsychiatry services, electronic prescribing is available. In compliance with federal and state law, all patients prescribed scheduled/controlled medications must be seen IN-PERSON AT LEAST ONCE per year to continue receiving prescriptions.
Drugs and other substances that are considered controlled substances under the Controlled Substances Act (CSA) are divided into five schedules. An updated and complete list of the schedules is published annually in Title 21 Code of Federal Regulations (C.F.R.) §§1308.11 through 1308.15. Substances are placed in their respective schedules based on whether they have a currently accepted medical use in treatment in the United States, their relative abuse potential, and likelihood of causing dependence when abused. Some examples of the drugs in each schedule are listed below.
SCHEDULE I CONTROLLED SUBSTANCES
Substances in this schedule have no currently accepted medical use in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.
Some examples of substances listed in Schedule I are: heroin, lysergic acid diethylamide (LSD), marijuana (cannabis), peyote, methaqualone, and 3,4-methylenedioxymethamphetamine (“Ecstasy”).
SCHEDULE II/IIN CONTROLLED SUBSTANCES (2/2N)
Substances in this schedule have a high potential for abuse which may lead to severe psychological or physical dependence.
Examples of Schedule II narcotics include: hydromorphone (Dilaudid®), methadone (Dolophine®), meperidine (Demerol®), oxycodone (OxyContin®, Percocet®), and fentanyl (Sublimaze®, Duragesic®). Other Schedule II narcotics include: morphine, opium, codeine, and hydrocodone.
Examples of Schedule IIN stimulants include: amphetamine (Dexedrine®, Adderall®), methamphetamine (Desoxyn®), and methylphenidate (Ritalin®).
Other Schedule II substances include: amobarbital, glutethimide, and pentobarbital.
SCHEDULE III/IIIN CONTROLLED SUBSTANCES (3/3N)
Substances in this schedule have a potential for abuse less than substances in Schedules I or II and abuse may lead to moderate or low physical dependence or high psychological dependence.
Examples of Schedule III narcotics include: products containing not more than 90 milligrams of codeine per dosage unit (Tylenol with Codeine®), and buprenorphine (Suboxone®).
Examples of Schedule IIIN non-narcotics include: benzphetamine (Didrex®), phendimetrazine, ketamine, and anabolic steroids such as Depo®-Testosterone.
SCHEDULE IV CONTROLLED SUBSTANCES
Substances in this schedule have a low potential for abuse relative to substances in Schedule III.
Examples of Schedule IV substances include: alprazolam (Xanax®), carisoprodol (Soma®), clonazepam (Klonopin®), clorazepate (Tranxene®), diazepam (Valium®), lorazepam (Ativan®), midazolam (Versed®), temazepam (Restoril®), and triazolam (Halcion®).
SCHEDULE V CONTROLLED SUBSTANCES
Substances in this schedule have a low potential for abuse relative to substances listed in Schedule IV and consist primarily of preparations containing limited quantities of certain narcotics.
Examples of Schedule V substances include: cough preparations containing not more than 200 milligrams of codeine per 100 milliliters or per 100 grams (Robitussin AC®, Phenergan with Codeine®), and ezogabine.
PLEASE NOTE: NO SERVICES WILL BE PROVIDED UNTIL PAYMENT IS MADE IN FULL. NO EXCEPTIONS.
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:
I RESERVE THE RIGHT TO DISCONTINUE OR TERMINATE CARE FOR ANY OF THE FOLLOWING REASONS AT ANY TIME:
NOTE: If care is terminated by Dr. Ingram, you will be provided enough psychotropic medication, if applicable, to last no more than thirty (30) days. It will be your responsibility to find a new provider.
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.
There is no guarantee of confidentiality under the following conditions:
Due to COVID-19, masks will be required for all in-office visits for all unvaccinated patients. If you’ve been vaccinated per the CDC guidelines, you are not required to wear a mask.
Please be sure to schedule a follow up visit in advanced. Last minute appointment requests may not be fulfilled as appointment slots fill up quickly. In the event of an emergency or crisis, you are instructed to go to the nearest emergency room and/or call 911 immediately.
DR. MICHAEL INGRAM PROVIDES A FEE-FOR-SERVICE MODEL OF CARE
Dr. Michael Ingram isn’t in your health plan’s network. This means Dr. Michael Ingram doesn’t have an agreement with your plan. The purpose of this statement is to let you know about your protections from unexpected medical bills. Receiving care from Dr. Michael Ingram could cost you more.
If your plan covers the item or service you’re getting, federal law protects you from higher bills:
If you sign this form, you may pay more because:
UNDERSTANDING YOUR OPTIONS
You are always welcome to receive care from other providers who are in-network with your health plan. Please contact your insurance company for a list of providers in-network. For more information about your rights and protections, please visit https://www.cms.gov for more information about your rights under federal law.
Pursuant to Assembly Bill (AB) 1278, physicians are required to provide a notice to their patients regarding the Open Payments database (Database), which is managed by the U.S. Centers for Medicare & Medicaid Services, or CMS. The Open Payments database is a federal tool used to search payments made by drug and device companies to physicians and teaching hospitals. It can be found at https://openpaymentsdata.cms.gov
For informational purposes only, a link to the federal Centers for Medicare and Medicaid Services (CMS) Open Payments web page is provided here. The federal Physician Payments Sunshine Act requires that detailed information about payment and other payments of value worth over ten dollars ($10) from manufacturers of drugs, medical devices, and biologics to physicians and teaching hospitals be made available to the public.
While a thorough diagnostic evaluation at the initial consultation visit provides Dr. Ingram with enough information to make one or more “provisional” diagnoses, it is important to remember that accurate diagnoses in psychiatric medicine develop over time (i.e., weeks to months) as Dr. Ingram gets to know his patients and their behavioral patterns. When appropriate, diagnoses will be given but should be viewed as provisional and subject to change. That is, diagnoses can evolve and change over time as new symptoms and patterns emerge.
Dr. Ingram is primarily concerned with each individual’s unique experience given that diagnoses do not adequately describe the complexity of a human being.
Medical doctors are licensed and regulated by the Medical Board of California. To check up on a license or to file a complaint go to http://www.mbc.ca.gov, email: firstname.lastname@example.org, or call (800) 633-2322.
MTI Psychiatry, Inc. [Dr. Michael T. Ingram, Jr., M.S., M.D.] is committed to protecting medical information about you. Please note that the Luminello EMR is HIPAA compliant and should be used for communicating with Dr. Ingram once care is established or for transferring information containing protected health information (PHI).
All services provided by MTI Psychiatry, Inc. [Dr. Michael T. Ingram, Jr., M.S., M.D.] follow the terms of the Notice of Privacy Practices. This notice, in compliance with federal privacy regulations, describes how information about you may be used and disclosed and how you can get access to this information. Dr. Ingram will review this with you at your first visit.
For more information about HIPAA please visit https://www.hhs.gov/hipaa or click here.
Patient confidentiality is important to us. Protected health information (PHI) will be maintained in a secure setting. Dr. Ingram uses Luminello, a user-friendly and HIPAA Compliant Electronic Medical Record (EMR). All forms or messages containing protected health information (PHI) will be sent through Luminello EMR and can be accessed through the Luminello patient portal. To access your unique patient portal through Luminello you must first receive an invitation email from Dr. Ingram. Call (213) 277-8372 for more information! After each visit, Dr. Ingram will document the encounter in Luminello. No protected health information will be disclosed to any entity without the written consent of the patient except in situations when federal or state law mandates disclosure of a patient’s protected health information. This will be reviewed at the patient’s first visit.
Please note that no person will be considered a patient of Dr. Ingram until after the initial visit.
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. MICHAEL INGRAM PROVIDES A FEE-FOR-SERVICE MODEL OF CARE
You agree to pay for services and fees as outlined in this PAYMENT POLICY AGREEMENT section. 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:
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.
Payment is due at the time of your scheduled appointment. No services will be provided until payment is received.
A deposit equal to half the initial consultation fee will be required to reserve your initial consultation visit. This deposit will not be refunded. Cancellations made within 24 hours of your initial consultation visit will result in forfeit of the initial consultation fee. Please note that rescheduling an initial consultation visit will not result in forfeiting of the initial consultation fee if you keep the appointment.
♦ Initial Consultation Visit, (75-90 Minutes): $1,000.00
♦ Follow Up Visit, (45 Minutes): $500.00
♦ Follow Up Visit, (25 Minutes): $350.00
♦ Follow Up Visit, (15 Minutes): $275.00
♦ Administrative Work/Phone Calls: $10.00/min
Unless other arrangements have been made, the rates above apply.
All phone calls and/or paper work requested outside of your scheduled appointment will be charged at a rate of $10.00/min. This includes obtaining collateral information from previous and/or current healthcare/mental health providers, family members, friends, and coordination of care. No phone calls or administrative work will be completed without your consent. That is, you will be billed ONLY for services you provided consent for.
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 at 949-436-9099.
Please be sure to keep your profile up to date. If you have a change of address, email, insurance, phone number, or emergency contact, please update this in your Luminello profile. An up-to-date Credit Card or Debit Card is required at all times. Please keep this updated by using the “billing” tab within your portal.
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.
NOTE: If it has been over 12 months since you’ve been seen for a follow up visit, then another consultation visit will be required to continue receiving treatment from Dr. Ingram.
**If you are using a health savings account (HSA) or flex debit card please check with your insurance provider as many HSA accounts may not allow processing through Luminello, Venmo, PayPal, etc.
As you know, it is Dr. Ingram’s policy to receive payment prior to your scheduled visit. No services will be provided until payment is received. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case. If you have questions about your treatment plan or the choice of payment options, please do not hesitate to ask. We are here to help you receive the healthcare you deserve.
If you choose to pay by PayPal, Credit Card, or Debit Card, then an additional processing fee of 3.99% will be charged in addition to the full fee of the visit.
You can generate your own insurance claim to submit to your insurance company for reimbursement by going to “Billing” and “Create Statement”. If needed, we are happy to do this for you and send to you as a PDF.
WHAT ARE ALL THE POTENTIAL FEES YOU COULD INCUR DURING TREATMENT WITH DR. INGRAM?
CANCELLATIONS/NO SHOWS: Not showing up to a scheduled appointment AND/OR canceling an appointment within 48 hours of your scheduled follow up appointment will result in your credit card or debit card being charged for the full rate/fee of the visit. If you are running late, please notify us immediately. If you are not at your appointment within 10 minutes after your scheduled appointment time, then your appointment will be canceled, and you will be charged the cancellation/No Show Fee.
INITIAL DEPOSIT: A deposit of half the initial consultation fee will be required to reserve your initial consultation visit. This deposit will not be refunded. Cancellations made within 24 hours of your initial consultation visit will result in forfeit of the initial consultation fee. Please note that rescheduling an initial consultation visit will not result in forfeiting of the initial consultation fee if you keep the appointment.
SCHEDULED APPOINTMENTS: Appointments are charged based on duration. Rates for appointments are listed above.
ADMINISTRATIVE WORK: All phone calls and/or paper work requested outside of your scheduled appointment will be charged at a rate of $10.00/min. This includes obtaining collateral information from previous and/or current healthcare/mental health providers, family members, friends, and coordination of care. No phone calls or administrative work will be completed without your consent. That is, you will be billed ONLY for services you provided consent for.