Patient Responsibilities

Insight Mental Wellness currently accepts Cigna, ChampVA, BCBSTX PPO, Humana, Optum/United Behavioral Health, Oscar, UMR, AARP Medicare Supplement, All Savers, Caprock, Community First, Freedom Life Insurance, Superior, Aetna, Amerigroup, Medicaid, Medicare, Ambetter, Triwest, Magellan, Beacon Behavioral Health, Gonzaba Medical Group, Golden Rule, Wellmed, Wellcare, insurance. Out-of-network services for patients wit the insurance listed below. We also offer private pay services.

Pending insurance authorizations:

  • Tricare
  • ComPsyc
  • Self-Pay (services rendered are fully paid by individual patient.) Inquiring, obtaining, and submission of required eligible forms for insurance reimbursement is totally the clients responsibility. If you wish to submit a claim to your insurance company, the staff can help with necessary clinic requested form(s).

We accept Cash, Debit Cards, or Major Credit Card payments only.

Notice of Privacy applies to all forms of services provided at the clinic. All medical records remain confidential and only released with your consent (verbal/written) authorizing disclosure of your information. However, if there is any information related to animal abuse, including cases of neglect and hoarding. Vulnerable Adults and Children: Mental health professionals are required by law to report stated or suspected abuse of a child or vulnerable adult to the appropriate social service agencies and/or legal authorities. Prenatal Exposure to Controlled Substances: in keeping with protecting vulnerable populations, Mental Health Providers are required to report admitted use of controlled substances during pregnancy that are potentially harmful to the fetus. Minors/Guardianship: Parents or legal guardians have the right to access a minor client’s health information.

Electronic Communication:

Be aware that emails (which may become part of your clinical record) and cell phone communication can be relatively easily compromised by unauthorized persons, which can compromise your confidentiality. If you choose to communicate with your healthcare provider via email or cell phone, it is strongly recommended that you limit such messages to scheduling inquiries. Please do not use email for urgent communications including clinical emergencies.

Due to computer or network problems, emails may not be received by your healthcare provider. If you have not heard from the clinic within 48 hours of sending your message, please resend and/or leave a voicemail message. Please notify us if you would prefer to avoid or limit, in any way, the use of email, texts, cell phone calls, phone messages or faxes.

Social Media / Contact Policies

Your healthcare professional is not permitted to accept friend or contact requests from current or former patients on any social networking site (Facebook, LinkedIn, etc.). Adding patients as friends or contacts can compromise your confidentiality and blur professional boundaries. If you have questions about this policy, please discuss them with your provider.

According to ethical standards and guidelines and to ensure your confidentiality, your healthcare professional is not permitted to have a relationship with you outside of your professional work together. Psychotherapy never involves any form of sexual or romantic contact before, during, or after the course of treatment.

It is your responsibility to contact your insurance company to confirm that Insight Mental Wellness is on your insurance panel, acquire pre-authorization for treatment, and confirm your personal policy benefits for “Outpatient Mental Health with Insight Mental Wellness” services before your first appointment. Be sure to state that this is for “outpatient mental health with Insight Mental Wellness” benefits, obtain information on your eligibility status, policy deductible, co-payments, co-insurance, and if needed provide information for the clinic or provider.

Clinic Availability: The clinic offers a messaging system after hours. Messages will be reviewed and responded to in the order received upon clinic reopen the next business day. Our healthcare professionals are available by appointment only. The clinic does not offer on-call/emergency services and there will not be staff responses after the regular clinic hours. Please do not use email for urgent communications including clinical emergencies. If you are having a medical or mental health emergency, please call 911 or go to a nearby emergency room for immediate care.

Financial Responsibility

It is the patient’s responsibility to understand their insurance benefits prior to being seen at Insight Mental Wellness. If insurance company denies services provided by Insight Mental Wellness, it is patients responsibility to pay for the service fees. Balances on my account are expected to be paid in full within 30 days of service. Self-pay patients and co-insurance/co-pays are required to be paid in full on the date of service with NO exceptions.

It is our number one priority at Insight Mental Wellness to provide the best quality of care to all of our patients. We understand that situations come up in life that are out of your control, however we do have cancellation lists full of patients that would like to be seen as soon as possible. Please call and cancel/reschedule your appointment NO LATER than 48 hours in advance. For initial evaluation appointment, we will charge a fee of $220 (insured) OR $280 (self-pay) for an appointment rescheduled/canceled later than 48 hours or no-show. For follow up appointments, we will charge $125 (insured) and $150 (self-pay) for an appointment rescheduled or canceled later than 48 hours or no-show. There is a fee of $125 for any psychotherapy/psychological evaluation appointment rescheduled later than 48 hours/no-show/same day cancelation. All fees must be paid prior to your next date of service.

Insight Mental Wellness reserves the right to terminate services after 2 incidents of rescheduling/no-shows/or same day cancelation of appointment. If the applicable fees are not paid by the follow up appointment, we will not be able to be schedule another appointment and the patient may be discharged from the practice.

Termination of Service(s):

The clinic reserves the right to terminate care if a case of patient noncompliance with treatment plan/medication management/follow up recommendations becomes the barriers to a successful treatment. We encourage you to discuss any concerns you have about our work together. Other factors that may result in termination of treatment by the clinic include, but are not limited to, violence or threats toward clinic/staff, irreconcilable differences, or refusal to pay for services in due time.

Legal representation:

Insight Mental Wellness clinic and staff DOES NOT provide any form of legal presentation to include but not limited to custody, visitation, any forensic matters or legal administrative proceedings.

The clinic will respond to any legal subpoena on your medical record. However, you will be responsible for any fees related to the clinic and staff time related to legal matters. Charges for court related services are not covered by insurance.

Patient Rights:

Right to file a complaint if you feel we have violated your rights, if you have a concern about your treatment at the clinic, or about your billing statement, by contacting us at 2102457862 or staff@im-wellness.com. We will take your concerns seriously, openly, and respond respectfully. You may request to speak with the Office Manager.

You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We can provide you with the appropriate address upon request. You have specific rights under the Privacy Rule. We will not retaliate against you for exercising your right to file a complaint.

Right to Request Restrictions –You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request. We will provide you with a reason for disagreement within 60 days.

Right to Receive Confidential Communications by Alternative Means and at Alternative Locations – You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. (For example, you may not want a family member to know that you are seeing us. Upon your request, we will send your bills to another address.)

Right to Inspect and Copy – You have the right to inspect or obtain a copy (or both) of PHI and/or notes in our mental health and billing records used to make decisions about you for as long as the PHI is maintained in the record. We may deny your access to PHI under certain circumstances, but in some cases, you may have this decision reviewed. On your request, we will discuss with you the details of the request and denial process. We will provide a copy or summary of your health record, within 30 days of your request. Contact the clinic for any applicable charges or fees.

Right to Amend – You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request. On your request, we will discuss with you the details of the amendment process. We will review the reason for denial of request in writing within 60 days.

Right to an Accounting – You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization. On your request, we will discuss with you the details of the accounting process.

Right to Restrict Disclosures When You Have Paid for Your Care Out-of-Pocket – You have the right to restrict certain disclosures of PHI to a health plan when you pay out-of- pocket in full for our services.

Right to Be Notified if There is a Breach of Your Unsecured PHI – You have a right to be notified if: (a) there is a breach (a use or disclosure of your PHI in violation of the HIPAA Privacy Rule) involving your PHI; (b) that PHI has not been encrypted to government standards; and (c) my risk assessment fails to determine that there is a low probability that your PHI has been compromised.

Effective Date, Restrictions, and Changes to Privacy Policy

We are required by law to maintain the privacy of PHI and to provide you with a notice of our legal duties and privacy practices with respect to PHI. We reserve the right to change the privacy policies and practices described in this notice. Unless we notify you of such changes, however, we are required to abide by the terms currently in effect. If we revise our policies and procedures, we will provide you with a revised notice by e-mail, unless you have requested to not be contacted via e-mail, in which case we will provide you with a revised notice via mail to the address you have provided.

This notice is effective as of January 3, 2022. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain. We will provide you with a revised notice by e-mail, unless you have requested to not be contacted via e- mail, in which case we will provide you with a revised notice via mail to the address you have provided.

Controlled Medications Contract Patient Responsibility

All Medications are Evaluated and Prescribed after careful review by your provider. If you are taking ‘Controlled Medications’, there may not be prescriptions issued on your initial Evaluation/Visit. Your Provider will access and make medication recommendations according to the Medical decision process and clinic policy.

  1. I agree to take any Controlled Substances exactly as instructed. I am NOT allowed to change the dose or number of times per day that I take my medication without first talking to my Controlled Substances.
  2. I agree to ONLY take these Controlled Substances prescribed by Insight Mental Wellness.
  3. I will not take Controlled Substances written by another provider or specialist unless I have notified my provider to filling my prescription.
  4. I agree to safekeeping my Controlled Substance prescriptions and medications. I understand that lost, misplaced, or stolen prescriptions or medications will not be replaced. If any of these situations arise that cause me to request an early refill of my medication, a copy of a filed police report or a statement from me explaining the circumstances may be required before additional prescriptions are considered. If I request an early refill secondary to lost, damaged, or stolen prescriptions twice within a year, I may be discharged from the practice.
  5. I will not sell this medicine or share it with others. I understand that if I do, my treatment will be stopped.
  6. I will bring in all my Controlled Substance medications in their original pill container to every appointment.
  7. I will bring in all Controlled Substance medications in their original pill container for random pill counts within 24 hours of when requested
  8. I will sign a release form to let the doctor speak to all other doctors or providers that I see. I will tell the doctor all other medicines that I take and let him/her know right away if I have a prescription for a new medicine.
  9. I agree that my prescribing physician has permission to discuss all diagnostic and treatment details with other health care providers, pharmacists, or other professionals who provide my health care regarding my use of controlled substances for purposes of maintaining accountability.
  10. I will NOT combine any controlled medication with consumption of alcohol. Any UDS that is positive for both Controlled Substances and alcohol will be considered a violation of this contract.
  11. I will NOT combine any controlled medication with illegal/street/recreational drugs. Any UDS that is positive for both prescribed Controlled Substances and illicit substances will be considered a violation of this contract.
  12. I will be responsible for making and keeping appointments for Controlled Substance refills at least every month or as indicated by my provider. I understand that NO refills will be written outside of my appointment and I will NOT contact the office for refills of these medications.
  13. I will be responsible for having a working phone number which the office will use to contact me about random UDS and pill counts. I understand that once notified by the office, either directly or by voicemail, I will have 24 hours to report, or inability to do so will result in a violation of this contract.
  14. I understand that not all insurances cover the cost of Drug Screening and that I may be responsible for part or the entire bill.
  15. I understand that I will not receive any Controlled Substances until my provider has been able to review my medical records. If I am a new patient, I understand that it is my responsibility to ensure my medical records have been obtained from my previous provider.
  16. I will not lie or tell misleading information to my provider or any of the IMW staff. I am aware that attempting to obtain a controlled substance under false pretenses is illegal.
  17. If the responsible legal authorities have questions concerning my treatment, as may occur, for example, if I obtained medication at several pharmacies, all confidentiality is waived, and these authorities may be given full access to my full records of controlled substances administration.
  18. I will not get angry or make threatening remarks in an attempt to get Controlled Substances
  19. I understand that these drugs should not be stopped abruptly, as withdrawal syndromes may develop.
  20. I understand that any medical treatment is initially a trial, with the goal of treatment being to improve the quality of life and ability to function and/or work. These parameters will be assessed periodically to determine the benefits of continued therapy, and continued prescription is contingent on whether my physician believes that the medication usage benefits me. I will comply with all treatments as outlined by my physician at IMW.
  21. I have been explained the risks and potential benefits of these therapies, including, but not limited to, psychological addiction, physical dependence, withdrawal and over dosage.

STIMULANTS: side effects to include but not limited to

  1. Sleep problems
  2. Decreased appetite   
  3. Delayed growth,     
  4. Headaches and stomachaches
  5. Rebound (irritability when the medication wears off).
  6. Moodiness and irritability.
  7. Tics repetitive movements: jerking or twitching (e.g., eye blinking- eye opening, facial or mouth twitching).
  8. Insomnia or trouble sleeping.
  9. Nightmares. 
  10. Stomachaches,
  11. Stares a lot or daydreams.
  12. Euphoric/unusually happy.
  13. Picking at skin or fingers, nail biting, lip or cheek chewing,  can cause your heart to beat faster or irregularly, raising your blood pressure.

SEDATIVE/HYPNOTIC side effects to include but not limited to:

  1. Headaches
  2. low blood pressure
  3. increased saliva production digestive disturbances
  4. Rashes sight problems (such as double vision)
  5. tremors (shaking)
  6. changes in sexual
    desire
  7. incontinence (loss of bladder control)
  8. difficulty urinating,
  9. drowsiness
  10. light-headedness
  11. confusion
  12. unsteadiness (especially in older people, who may have falls and injure themselves as a result)
  13. dizziness
  14. slurred speech
  15. muscle weakness
  16. memory problems
  17. constipation
  18. nausea (feeling sick)
  19. dry mouth
  20. blurred vision,
  21. difficulty concentrating
  22. feeling dulled and slow
  23. feeling isolated and unreal
  24. feeling cut off from your emotions
  25. irritability and impatience
  26. loss of confidence
  27. weight problems,
  28. Respiratory compromise can be fatal if taken with alcohol,other drugs/medications such as opioid, or diagnosis of chronic obstructive pulmonary disease (COPD) /obstructive sleep apnea (OSA).

Consequences of NOT adhering to any part of this Contract:

  1. Our office/providers will no longer:

    a. Prescribe any controlled substance for you. It will be at provider discretion to decide if a taper of medication will be given.

    b. May stop providing medical care for you

    c. May refer you for drug abuse treatment

    2. We will not prescribe controlled substances for you.

    Should you be discharged from our practice due to breakdown of provider/patient communication, your

    provider will provide 30 days of care from the date of discharge. This may not apply to Controlled

    Substances if the reason for discharge was a violation of this contract.

    I, attest that the foregoing was reviewed and that I have read, fully

    understand, and agree to all of the above requirements and instructions.

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