POLICIES

 EMERGENCIES Mindset Behavioral Health PC is a private practice and we do not provide emergency / crisis services. For medical / behavioral healthcare emergencies, please call 911, go directly to the nearest emergency room.

COMMUNICATING WITH OUR OFFICE (Appointment Scheduling/Cancellations, Medication Issues/Questions

Osmind PATIENT PORTAL ***Best Option***

We strongly recommend that if you are not yet connected to our practice patient portal, Osmind, that you do so as soon as possible. Osmind is a HIPAA-compliant, secure messaging system that you can use to connect with Mindset Behavioral Health for almost all your needs. Using Osmind allows you to have more clear communication with your clinician as they will receive your message in your own words. It also allows for a record of our communication and provides us with a way to provide you with more detailed information to which you can later refer if you have questions. Messages sent through Osmind portal are received by our staff more quickly, since these messages are available in our system as they come in throughout the day as opposed to voice mail messages which are typically retrieved limited times throughout the day. • EMAIL Is the next best option to send a quick communication to our staff. New Patient appointments and all other requests: contact@mindsetbh.com

Payments  can be made through the portal or on our website at mindsetbh.com,  TELEPHONE 317-207-0277. 

Our office receives well over 1,000 phone calls each day, so using the patient portal when appropriate provides our staff with a greater ability to field phone calls for issues better addressed through real-time communication. 

 MEDICATION RELATED POLICIES: We highly encourage you to address all questions and concerns at the time of your appointment. 

*Medication refills WILL NOT be called in outside of normal business hours, weekends, or holidays. 

MEDICATION REFILLS / QUESTIONS / CONCERNS: It is recommended patients check with their pharmacy to verify there are no refills on file or on hold before contacting our office. Sometimes prescriptions are held if they are issued prior to the acceptable refill date. If a refill is necessary, for the quickest response, please request your refill via our patient portal. If you do not have a portal account set up, please see “COMMUNICATING WITH OUR OFFICE” on listed above for additional ways to reach us. 

AUTOMATED PHARMACY REFILL REQUESTS: Mindset Behavioral Health DOES NOT accept automated pharmacy fax refill requests. Our office receives hundreds of automated fax refill requests daily for medications with a vast majority of those requests being for medications that have been changed or discontinued. Pharmacies are typically unaware of this information. We ask that you initiate all refill requests. 

PRIOR AUTHORIZATIONS (PA) FOR MEDICATIONS: Insurance companies often require a prior authorization be completed. This is a process they use to determine if they will cover the cost of the medication that has been prescribed for your care. The PA will be initiated by your insurance. Our office will submit the requested information to your insurance company. Please note that the final determination is made by your insurance, not Mindset behavioral Health/your medical provider. 

 BILLING & INSURANCE POLICY 

• Private Pay Services / Out of Network Insurance Billed Services - Payment is due at the time of service and must have credit card on file.  
• Insurance Billed Services - Co-payments & deductibles are due at the time of service and must have credit card on file
• Insurance Participation - Our providers participate with different insurance plans. We make every attempt to schedule you with an in-network provider; however, we cannot guarantee that the provider you are scheduled with is active in your network. It is the patient responsibility to confirm that any/all providers with whom they are scheduled are participating in their insurance network. Patients will be responsible for charges incurred for services rendered by an out-of-network provider. 
• Insurance Benefits - Please be aware that mental health benefits are normally different from your medical benefits. Mindset Behavioral Health does not verify insurance benefits information until after your initial visit with our group. It is your responsibility to verify and familiarize yourself with your mental health benefits. 
• Changes to Insurance – It is your responsibility to make sure we have your most current insurance card on file. Sometimes insurance may change to a different insurance company, other times it may just be a simple change to your ID number. Anytime you receive a new card, please notify our office or you can upload a copy through our website. 
•  Claims Submission - We will file all claims with your primary insurance company upon submission of proof of insurance. Mindset Behavioral Health will file secondary insurance claims for contracted insurance carriers only. 
• Past Due Balances - Our office reserves the right to cancel or refuse services for patient accounts with past due balances. Patients will be unable to schedule appointment if they have 2 outstanding co-payments, an account balance of $100 or more, or if your account balance is greater than 30 days past due after insurance processing. 
• Returned Check Fees - All returned checks would be assessed with a $30 processing fee. The original check amount plus the processing fee must be paid at your next appointment or within 10 days, whichever occurs first. Mindset Behavioral Health reserves the right of check refusal. 
•  Statements - Maybe accessed through the patient portal. We do not mail statements.  Payment in full at the time of the appointment, we require a credit card to be on file. •
•  Claim / charge dispute - Therapist, doctors, nurses, clerical staff, and/or billing department personnel are unable to waive or modify fees. The decision rests with the administration of Mindset Behavioral Health. The patient must complete contact our office in writing for a claim or charge dispute
• Financial Responsibility - The patient / responsible party are responsible for all charges incurred with Mindset Behavioral Health. 
• Collections - Accounts in violation of our financial policy are subject to placement with a third-party collection agency. The patient will be responsible for reasonable attorney and collection fees. 

 OUT OF NETWORK BILLING POLICY 

•  Private Pay Services / Out of Network Insurance Billed Services - Payment in full is due at the time of service. We will provide a superbill at your request.

 SOCIAL MEDIA POLICY As technology continually changes, Mindset Behavioral Health reserves the right to revise this policy. 

Contacting Mindset Behavioral Health  via Text or Social Media - Please do not use mobile text messaging or messaging on social media sites such as Twitter, Facebook, or LinkedIn to contact Mindset Behavioral Health. These sites are not secure. Engaging Mindset Behavioral Health this way could compromise your confidentiality. It may also create the possibility that these exchanges become a part of your legal medical record and would need to be documented and archived in your chart. 

Social Media - Mindset Behavioral Health and its staff do not accept “friend” requests from current or former clients, or family members of clients, on Facebook, Instagram, Twitter, or other similar social media sites. Mindset Behavioral Health believes that adding clients as friends or contacts on these sites can compromise confidentiality and our respective privacy. It may also blur the boundaries of the therapeutic relationship. If you have questions about this, please bring them up when during a meeting and these issues can be discussed further. 

Location-Based Services - If you or your family member has locations enabled on a mobile device, or you check in on a social media site, it could identify you as a patient at Mindset Behavioral Health. Please be aware that this compromises your confidentiality.

Business Review Sites - You may find Mindset Behavioral Health on sites such as Google, Yelp, Healthgrades, Yahoo Local, Bing, or other places which list businesses. Some of these sites include forums in which users rate their providers and add reviews. Many of these sites comb search engines for business listings and automatically add listings regardless of whether the business has added itself to the site. If you should find Mindset Behavioral Health listing on any of these sites, please know that the listing is NOT a request for a testimonial, rating, or endorsement from you as a client. Of course, you have a right to express yourself on any site you wish but due to confidentiality, Mindset Behavioral Health  cannot respond to any review on any of these sites whether it is positive or negative. 

 TELEHEALTH POLICY 

 Confidentiality: Our office utilizes  Doxy.me or Zoom a confidential, HIPAA compliant audio/video conferencing application, for all telehealth appointments. Mindset Behavioral Health is not responsible for breach of confidentiality when using any other telehealth platform including over the telephone or via email.  

 I agree Mindset Behavioral Health and its members, directors, partners, employees, and agents shall not be liable for any breach of confidentiality or privacy arising from teletherapy with me. I agree that I shall fully defend and hold Mindset Behavioral Health  harmless for principal, interest, court costs and reasonable attorneys' fees, together with any judgment rendered against it because of or arising from this Request to Use, Informed Consent, and Agreement Regarding Use of Teletherapy.

•  I agree to waive all claims against or liability of and shall hold harmless Mindset Behavioral Health and its members, directors, partners, employees, and agents for any breach of confidentiality or privacy arising from teletherapy/telemedicine with me. 
•  I agree I am signing this Informed Consent voluntarily and my signature is not the result of duress or undue influence. 
• I agree I have asked Mindset Behavioral Health all questions I had regarding this Informed Consent, and such questions were answered to my satisfaction. 
• I agree that this Request to Use, Informed Consent, and Agreement Regarding Use of Teletherapy/Telemedicine represents the entire understanding regarding the subject matter herein. I agree that none of the terms of this Request to Use, Informed Consent, And Agreement Regarding Use of Teletherapy/Telemedicine can be waived or modified, except by an express agreement signed by me and Mindset Behavioral Health. I agree there are no representations, promises, warranties, covenants, or undertakings by Mindset Behavioral Health other than those expressly set forth in this Agreement. 
•  This Request to Use, Informed Consent, And Agreement Regarding Use of Teletherapy/Telemedicine is made and executed in the State of Indiana and shall be governed and always construed according to the laws of that state even though I may later reside or be domiciled outside of Indiana. 

PATIENT RIGHTS

• To be treated with respect and recognition of my dignity and right to privacy Receive care that is considerate and respects my personal values and belief system 
• Personal privacy and confidentiality of information Reasonable access to care, regardless of my race, religion, gender, sexual orientation, ethnicity, age, or disability
• Participate in an informed way in the decision-making process regarding my treatment planning Discuss with my treating professionals appropriate/medically necessary treatment options for my condition regardless of cost / benefit coverage 
• Adequate and humane services regardless of the source(s) of financial support An individualized treatment or program plan with periodic review of the treatment or program plan Designate a decision maker if I am incapable of understanding a proposed treatment or procedure or am unable to communicate my wishes 
• Voice complaints or appeals about my managed care company, provider of care or privacy practices 
• Be informed of rules and regulations concerning my own conduct
•  Request access to my Protected Health Information (PHI) 
• Request to inspect and obtain a copy of my PHI, to amend my PHI or to restrict the use of my PHI, and to receive an accounting of disclosures of PHI 

 PATIENT RESPONSIBILITIES 

• MINDSET BEHAVIORAL HEALTH PC, and I agree and consent to participate in the mental health services offered and provided by a mental health provider as defined in Indiana law.
•  I agree to provide (to the extent possible) my treating clinician with information needed to receive appropriate care.
•  I understand that it is my responsibility to understand my health problems and participate, to the degree possible, in developing, with my treating clinician, mutually agreed upon treatment goals. 
• I understand that it is my responsibility to follow plans and instructions for care that I have agreed on with my treating clinician 

 NOTICE OF PRIVACY PRACTICES  

 THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED. PLEASE REVIEW IT CAREFULLY. OUR PLEDGE REGARDING HEALTH INFORMATION: 

We understand that health information about you is personal. We are committed te to protecting health information about you. Mindset Behavioral Health, PC  will create a record of the services you receive at our offices. We need this record to provide you with quality services and to comply with certain legal requirements. We are required by law to: Make sure that health information that identifies you is kept private; Give you this notice of our legal duties and privacy practices regarding health information about you; and follow the terms of the notice that is currently in effect 

 HOW WE ARE REQUIRED BY LAW TO DISCLOSE HEALTH INFORMATI ON ABOUT YOU WITH AND WITHOUT YOUR AUTHORIZATION. 

 As Required by Law . We will disclose health information about you when required to do so by federal, state, or local law. 

Public Health Risks/Threats. We will disclose health information about you for public health reporting required by federal or state law. These activities generally include the following: To prevent or control disease, injury or disability; To report deaths; To report potential/ actual child abuse or neglect ; To report reactions to medications or problems with products; To notify people of recalls of products they may be using; To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; To notify the appropriate government authority if we believe an individual served has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. 

Health Oversight Activities. These oversight activities include, for example, audits, investigations, inspect ions, and licensure. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we will disclose health information about you when properly ordered to do so by a court or law enforcement. We will release health information if asked to do so by a law enforcement official, and if permitted by law: In response to a court order; To identify or locate a suspect, fugitive, material witness, or missing person; About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; About a death we believe may be the result of criminal conduct; About criminal conduct at the offices of Mindset Behavioral Health. In emergency circumstances to report a crime; the location of the crime or victims; or the identity, descript ion or location of the person who committed the crime 

OTHER WAYS WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU WITH AND WITHOUT YOUR WRITTEN AUTHORIZATION. 

The following categories describe different ways that we use and disclose health information: 

Treatment. We may use health information about you to provide you with clinical treatment or services. We may disclose health information about you to clinical providers and support staff personnel who are involved in providing services to you. 

Payment. We may use/disclose health information about you so that the services you received through Mindset Behavioral Health may be billed to, and payment may be collected from you, an insurance company or a third party. For example, we may need to give your insurance company information about services you received at Mindset Behavioral Health to receive payment. We may also tell your insurance about a service you are going to receive to obtain prior approval or to determine whether your insurance will pay for the service. 

For Health Care Operations. We may use/disclose health information about you to another health care provider or health plan, if you have given us written authorization to do so. 

Appointment Reminders. We may use and disclose health information about you to contact you as a reminder that you have an appointment with staff of Mindset Behavioral Health. You have a right to request confidential communications in a specific manner or at a specific location. Please remember you will need to inform us in writing if you do not wish to be contacted for the purposes of appointment reminders. Staff will be available to assist you on completing this written request. 

Treatment Alternatives. We may use and disclose health information to tell you about or recommend possible treatment opt ions or alternatives that may be of interest to you. Health-Related Benefits and Services. We may use and disclose health information to tell you about health- related benefits or services that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. We may release certain limited information about you to a family member who is your parent or guardian as allowed by federal and state law. We may also give information to a parent or guardian that is responsible to pay for the services you are provided through Mindset Behavioral Health. 

Disaster Relief. We may disclose health information about you to an entity assisting in a disaster relief effort, so your family can be notified about your condition, status, and location. 

Research. Under certain circumstances we may use/disclose health information about you for research purposes. Before we use/disclose information about you that reveals who you are (name/ address) we will obtain your written authorization. 

 SPECIAL SITUATIONS 

 Military/Veterans If you are a member of the armed forces; we may release health information about you as required by military authorities. We may also release health information about foreign military personnel to appropriate foreign military authority. 

 Coroners/Medical Examiners. We may release health information to a coroner/medical examiner. This may be necessary, i.e. to identify the cause of death.  

 National Security and Intelligence Activities. We may release health information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.  

 Inmates. I f you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release health information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. 

 YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU 

 You have the following rights regarding health information we maintain about you: 

 Inspect and Copy - You have the right to inspect and copy your Protected Health Information. To exercise this right, you must submit your request, in writing, to Mindset Behavioral Health We may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy under limited circumstances. If we deny you access to your PHI, you may in some cases request review of the denial. Mindset Behavioral Health will choose a licensed healthcare professional (who did not take part in denying your request) to review your request and the denial. We will comply with the outcome of the review. 

To Request to Amend -health information we have about you if you feel that it is incorrect or incomplete. You have a right to request an amendment for as long as the information is kept by Mindset Behavioral Health. To request an amendment, your request must be made in writing and submitted to Mindset Behavioral Health. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include the reason to support the request. In addition, we may deny your request if you ask us to amend info.

 To an Accounting of Disclosures. This is a list of the disclosures we made of health information about you. To request this list or accounting of disclosures, you must submit your request in writing to Mindset Behavioral Health. Your request must state a period, which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs for providing list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before the cost are incurred. 

 To Request Restrictions on the health information we use or disclose about you for treatment, payment, or health care operations. You also have the right to request a limit on the heath information we disclose to someone who is involved in your care or the payment of your care, like a family member or friend. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to Mindset Behavioral Health. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. 

 Right to Request Confidential Communications. You have a right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to IMindset Behavioral Health. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. 

 COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with group administrator of Mindset Behavioral Health or with the Secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint. 

 OTHER USES OF HEALTH INFORMATION Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. I f you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. 

 CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at each of our locations. If you have any questions about this notice, please contact Mindset Behavioral Health at 317-207-0277