—Office policies—
Heike Sommer, PMHNP-BC
503-567-4216
This statement contains information regarding my office policies. Please read them and, if you have any questions, please discuss them with me. Your signature at the bottom of this sheet signifies you have read, understood, and agree to abide by these policies, and that you have received a copy of the policies yourself.
Appointments Your appointment time is held exclusively for you—please arrive on time (or a few minutes early) so we can make the best use of your time. If you are unable to keep an appointment, please provide at least 24 hours-notice or you will be charged for the time as though you attended. Please note that insurance companies will not cover this charge and you will be responsible for covering the $190 fee in full.
Emergencies In case of an urgent matter, you may reach me between appointments through my voicemail. I check messages frequently. If you need immediate support for an emergency, you may contact the Crisis line at 503.988.4888. When I am out of town, I or another clinician will be available. In order to reserve time for the clinically urgent needs of patients, I thank you in advance for your help in decreasing the volume of phone calls so I can devote myself to your clinical needs.
Insurance We are happy to bill your insurance as a courtesy. You are responsible to check with your insurance company regarding your coverage and to track this coverage as treatment progresses. Some things to keep in mind are: Are you currently covered? Am I a provider whose services are paid under this plan? What is your annual deductible? What is the percentage of coverage? What is the maximum benefit for outpatient mental health coverage? Remember: You are responsible for bills whether insurance pays or not.
Billing You will receive a statement from my office if you have a remaining balance after all payments from insurance and yourself have been posted. All outstanding balances are due upon receipt of your statement. If such payment is not made, a $25.00 rebilling charge will be assessed for the month. Should the bank return your check, there will be a $25.00 returned check charge. Ultimately, if you do not pay as agreed, your account may be turned over to a collection agency for collection and you will be held responsible for any legal or collection costs incurred.
Confidentially and the Release of information Your participation in treatment and all information about you is confidential and will not be disclosed to anyone without your written consent. The only exceptions are: A) cases of suspected abuse or neglect of a child or elder, B) cases where I believe the client presents a clear and imminent danger to him/herself or to another person, C) cases where a court subpoenas me to testify or subpoenas my records or D) cases where an insurance company is helping to pay your fee and requires information about diagnosis and/or reports about treatment. To further ensure your confidentiality, please remember that cell phone calls and email communications are not secure.
HIPPA Notice of Policies and Practices I am committed to preserving the privacy of your own personal health information. Additionally, I am required by the Federal law (Health Insurance Portability and Accountability Act, known as HIPPA), and by State law to protect the privacy of your personal information and to offer you a Notice that describes (a) how clinical information about you may be used and disclosed and (b) how you can get access to this information. Please ask for a copy of the HIPPA Notice of Policies and Practices should you wish to have a complete copy for your records.
By filling out the form below, you agree to the policies stated above.