I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent. I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before our session begins. I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I must be a resident of the State of South Carolina to be eligible for telepsychiatry services from Taral Sharma M.D., P.C. I understand that my psychiatrist/therapist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter. I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow-up face-to-face visit, or a second telepsychiatry visit. I can change my mind and stop using telepsychiatry at any time, including in the middle of a video visit. This will not make any difference to my right to ask for and receive health care.

I understand that there are risks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of m psychiatrist/therapist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons. In addition, I understand that telepsychiatry based services and care may not be as complete as face-to-face services. I also understand that if my psychiatrist/therapist believes I would be better served by another form of psychiatric services (e.g. face-to-face services) I will be referred to a psychiatrist/therapist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry, and that despite my efforts and the efforts of my psychiatrist/therapist, my condition may not improve, and in some cases may even get worse.

I hereby consent to engaging in telepsychiatry with Taral Sharma M.D., P.C. as part of my psychiatric evaluation and treatment. I understand that “telepsychiatry” includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.

At my own discretion I am requesting treatment at Taral Sharma M.D., P.C. I know that my treatment may consist of pharmacotherapy and/or psychotherapy. I will be educated on the benefits and potential side effects or reactions that may result from any prescribed medication. I am aware that I have the right to request a copy of the Physician Desk Reference for my use. I have the right to ask questions regarding my treatment and expect that my questions will be answered to my full satisfaction. If I do withdraw from treatment, I have the right to have a referral sent to another practitioner for alternative treatment. I allow Taral Sharma M.D., P.C. to make this document a permanent part of my patient record.

I understand and will expect that all papers and documents concerning my treatment at Taral Sharma M.D., P.C. will be kept confidential. My treatment information cannot be released without my written consent unless required by law or in a situation that is potentially life-threatening. According to Federal Regulations, licensed providers are mandated to report information that professional judgement would determine constitutes threat or serious harm to self or others, or indicates child or elder abuse or neglect.

I understand that I have a right to access my medical information and copies of medical records in accordance with South Carolina Law. Patient’s Responsibilities I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent. I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before our session begins. I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins. I understand that I must be a resident of the State of South Carolina to be eligible for telepsychiatry services from Taral Sharma M.D., P.C. I understand that my psychiatrist/therapist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter. I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow-up face-to-face visit, or a second telepsychiatry visit. I can change my mind and stop using telepsychiatry at any time, including in the middle of a video visit. This will not make any difference to my right to ask for and receive health care.

I acknowledge that Taral Sharma M.D., P.C. provided me with the option to obtain a written copy of Notice of Privacy Practices. I also acknowledge that I have been offered the opportunity to read the Notice of Privacy Practices and ask questions.

Your relationship with your doctor is at your discretion. You have the right to seek mental health treatment from any provider with whom you feel comfortable. If you have concerns about the quality of services provided, concerns with staff, building, or billing, please let your provider know. Awareness of these issues will strengthen our working relationship and in no way effect the quality of care you receive at our clinic. We reserve the right to terminate services provided by our office if anyone behaves inappropriately towards a provider or office staff, if there is non-compliance with attending appointments, providing payment for services, or if either patient/parent does not consent for services for a child. Your signature below indicates that you have read the above information and agree to abide by these terms during our professional relationship.

When our office schedules your appointment, we are setting aside a dedicated time slot just for you. We ask that if you reschedule your appointment, that you please let us know 24 hours in advance. If you no call no show your appointment you will be charged $100 no show fee. Your insurance will not be responsible for paying this fee. If you are more than ten minutes late for your appointment, we will need to reschedule your appointment. We reserve these time slots specifically for you. If you are late, your appointment time runs over into the next patient’s appointment time causing scheduling conflicts and less time for other patients to be seen. If you no call no show three times, this will result in loss of future appointment privileges.

Introduction:
Like many new procedures, it will be difficult or impossible to get reimbursement for Esketamine administration codes. Insurance reimbursement for our more traditional services will be similar for Taral Sharma M.D., P.C. as for other providers you may have used. In order for us to set realistic treatment goals and priorities, it is important to evaluate what resources you have available to pay for your treatment. If you have a health insurance policy, it will usually provide some coverage for mental health treatment. We will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled, however, you (not your insurance company) are responsible for full payment of fees. It is very important that you find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator. Of course, we will provide you with whatever information we can based on experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. “Managed Health Care” plans such as HMOs and PPOs often require authorization before they provide reimbursement for mental health services. These plans are often limited to short-term treatment approaches designed to work out specific problems that interfere with a person’s usual level of functioning. It may be necessary to seek approval for more therapy after a certain number of sessions. While a lot can be accomplished in short-term therapy, some patients feel that they need more services after insurance benefits end. You should also be aware that most insurance companies require you to authorize us to provide them with a clinical diagnosis. Sometimes we have to provide additional clinical information such as treatment plans or summaries, or copies of the entire record (in rare cases). We will provide you with a copy of any report we submit if you request it. Once we have all of the information about your insurance coverage, we will discuss what we can expect to accomplish with the benefits that are available and what will happen if they run out before you feel ready to end our sessions. It is important to remember that you always have the right to pay for services yourself to avoid the problems described above unless prohibited by contract.

Thank you for choosing Taral Sharma, M.D., P.C. as your healthcare provider. We are committed to building a successful physician-patient relationship with you and your family. Your clear understanding of our Patient Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, our policies, or your responsibilities. It is your responsibility to notify our office of any patient information changes (i.e. address, name, insurance information, etc.). Private Insurance: As a courtesy, we will file a claim on your behalf if you have private insurance. You will be responsible for any Copayments or Coinsurance. After your insurance company has made payment, you will be billed for any remaining patient responsibility portion of the covered services. You are also responsible for any services not covered by your insurance company. It is your responsibility to provide all necessary information so that we may process your claims in a timely manner. If we are unable to process claims with your insurance company, you will be held responsible for the charges. Out-of-Network Insurance Provider: Please understand that some insurance coverages have Out-of-Network benefits that have co-insurance charges, higher co-payments, and limited annual benefits. If the services or lab tests you receive are part of an Out-of-Network benefit, your portion of financial responsibility may be higher than the In-Network rate. Medicaid/MCO: If we are able to verify your Medicaid or Managed Care coverage, we will submit all Medicaid/MCO claims for you. It is your responsibility to provide all necessary information so that we may verify eligibility and process your claims in a timely manner. If you lose your Medicaid/MCO eligibility, you will be held responsible for the charges. Medicare: We do accept Medicare patients and will submit all claims to Medicare. You will be responsible for any Copayments or Coinsurance. It is your responsibility to provide all necessary information so that we may verify eligibility and process your claims in a timely manner. Payment: Please understand that payment of your bill is considered part of your treatment. Payment can be made by cash, check, or credit card. I have read the financial policies contained above, and my signature below serves as acknowledgement of a clear understanding of my financial responsibility.

By signing below, you agree to the terms and conditions outlined herein, to the best of your knowledge" means that by signing the document, you are confirming that you have read and understood the terms and conditions presented, and that you agree to them based on what you have been informed, even if there may be aspects you are not completely certain about.