History of Presenting Problem
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Past Hospitalizations, Counseling or Therapy
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Past Psychiatric History
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Psychiatric Medication History
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Substance Use History
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Medical History
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Family History
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This Section is For Women Only
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Social History
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Education
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Legal History
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Employment/Vocational History
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Review of Systems
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I authorize exchange of information between Melissa Sullivan Psychiatry, PLLC and my treating physician regarding my care.
My treatment and care will be confidential except under the following circumstances:
- Threat of imminent harm to self or others
- Allegations of recent or ongoing abuse to another individual
- A court-ordered subpoena of records
The documentation maintained about my case is the property of Melissa Sullivan Psychiatry, PLLC. Only with my written authorization can this information be released to another physician, service provider or agency. I understand that receiving psychiatric or psychological treatment and having a psychiatric diagnosis may adversely affect my ability to obtain life, disability or long-term insurance. I agree to release Melissa Sullivan Psychiatry, PLLC from any liability if I have difficulty obtaining insurance due to the contents of my medical records.
I authorize the release of any information requested by my insurance carrier or pharmacy regarding the dispensing of prescribed medications including, but not limited to, diagnosis and health history. I authorize the release of any clinical or demographic information required by a laboratory to perform test requested by Melissa Sullivan Psychiatry, PLLC.
I understand that if I have not been seen face-to-face by Melissa Sullivan Psychiatry, PLLC in over a year, I am no longer considered to be an active patient. I agree to release any form of medical liability for events occurring one year after the face-to-face content.
I understand that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is my responsibility to pay all fees in full. I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.
In order to control the costs of billings, I understand the charges for office visits are to be paid at the beginning of each visit.
I understand that if I have a balance on my account that is over 90 days old it will be subject to being referred to a collection agency. Any personal information needed to collect the debt will be provided to the collection agency. If this account is assigned to an attorney for collection and/or suit, the practice shall be entitled to reasonable attorney’s fees and costs of collection.
This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I understand that I am financially responsible for all charges whether or not paid by said insurance.
I understand that I will be billed in full for missed appointments or appointments not canceled by giving 24-hour notice.
I understand that I may be billed for prescription phone calls and phone consultations.
I understand that interest at the rate of 18% per annum will be assessed to delinquent accounts.
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The primary mission of Melissa Sullivan Psychiatry, PLLC is to provide the highest quality mental health and substance use services for individuals 18 years of age and older residing in Kentucky. The range of services provided include outpatient psychotherapy and psychopharmacology management. We endeavor to meet the needs of our patients and referral sources in a timely, efficient, courteous and professional manner.
In return for this conscientious care, we ask our patients to cooperate with the following guidelines:
Initial Visit
We will review intake paperwork prior to this visit and then interview patient to determine a diagnosis. A treatment plan will then be designed with the patient. It may include hospitalization, medications, routine lab tests, individual therapy or family therapy. There are times that the needs of the patient may be in excess of the resources available in this practice. If this is the case, appropriate referrals will be suggested.
Office Hours
Standard appointments are scheduled Tuesdays through Thursdays from 9:00 a.m.-4:30 p.m. New patient evaluations and emergency appointments are reserved for Mondays and Fridays.
Appointments
Patient visits are by appointment only. Our office will make every effort to adhere to our schedule so that you are seen on time. However, emergencies do occur and you will be advised if the doctor is running behind. In turn, we ask you to be punctual. If you are late by more than 10 minutes of the scheduled appointment time, you may be rescheduled. This will be considered a less than 24-hour cancellation.
If you cannot keep an appointment, please call our office as soon as possible. Failure to keep an appointment or cancel 24 hours in advance will result in a charge of $130. Please note that insurance companies do not pay for missed appointment charges. Such charges are the responsibility of the patient. We have a voicemail system that takes messages 24 hours a day. Patients who frequently miss scheduled appointments may be terminated from the practice for noncompliance.
Emergencies
If you have a medical or psychiatric emergency (such as suicidality), call 911 immediately. If you have an urgent matter, please call the office at (502) 657-4551 24 hours a day/7 days a week.
Fees and Billing
Please refer to the financial policy enclosed in this packet.
Medications
Refills for controlled substances and/or schedule II medications will not be given early for any reason including theft or loss of medication.
Hospitalization
Dr. Sullivan will see patients in the office only. If hospitalization is required, the patient will be referred to the hospital that is covered by his or her insurance company. The admission and ongoing treatment while in the hospital will be at the discretion of the on-call physician at the hospital, but Dr. Sullivan will be available for a phone consultation with the physician, should that physician request it. Upon discharge, the patient is encouraged to schedule a return appointment with Dr. Sullivan as soon as possible.
Medical Records (Protected Health Information)
We request that all patients advise us before treatment if they are involved in a lawsuit. Our records concerning your treatment are strictly confidential. Such information is available to referring and treating physicians so that your care can be complete. We will ask you to sign a release of information to do these positions at your first visit. However, your information may be disclosed to your insurance carrier as part of the insurance contract for payment and may be disclosed to your pharmacy or laboratory as needed. A full notice of privacy practices is to be posted in the office and you may request a copy.
Forms and Phone Calls
Patients will be billed for time spent completing forms not relating to billing of charges for services received in this office.
Patients may also be billed for phone calls involving the doctors. Insurance companies do not pay for phone calls.
Patient Responsibility
To assure that your receive the quality care you deserve, please assist us by doing the following:
- Notify our business office of any changes in your residence, phone number or insurance.
- Keep your appointments as scheduled or notify the office at least 24 hours in advance of any change.
- Be prepared to pay for your office appointment on the day in which you are seen or arrange a payment plan prior to your visit.
- Monitor your medication so that you do not run out between appointments.
- Notify us in advance of any need to release your records for legal or other purposes. It could take up to 10 business days to compile the needed records/information.
- Be truthful with the doctors and staff.
- Follow the agreed treatment plan.
Termination of Care
Either the patient or the doctor can terminate the doctor/patient relationship for any reason he or she deems appropriate.
Reasons for termination could include:
- Providing misleading or untruthful information
- Not following the agreed treatment plan
- Using medication outside the prescribed directions resulting in request for early refills
- Excessive, unwarranted phone calls during workday and/or after hours
- Repeated failure to keep appointments
- Failure to tell us that you were in a lawsuit or facing criminal charges
- Failure to comply with the financial policy
- Aggressive or inappropriate behavior towards doctors/staff
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Notice of Privacy Practices
This Notice describes how your medical information may be used and disclosed and how you may access your information. Please review it carefully. If you have any questions about this Notice, please contact our office manager. This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment of health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control you protected health information. “Protected health information” hereafter referred to as PHI) is information about you, including demographic information, that may identify you and that related to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice of Privacy. We may change the terms of our notice at any time. The new notice will be effective for all PHI that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked by your physician to sign a treatment authorization form, which indicates that you consent to use and disclosure of your PHI for treatment, payment and health care operations. Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your PHI may also be used and disclosed to pay your health care bills and to support the operation of the physician’s practice. Following are examples of circumstances where use and disclosure of your PHI are permitted (this list is descriptive but not exhaustive):
- The coordination or management of your health care with a third party, such as a home health agency, the physician who referred you to our office or to whom our doctors have referred you.
- Diagnoses and billing information provided to laboratories for requested testing.
- Diagnoses, billing information and medication prescribed made available to pharmacies.
- Determination of eligibility and insurance benefit coverage, medical necessity review and utilization reviews activities.
- We may call you by name in the waiting room when your physician is ready to see you.
- We may leave a message for you on your voice mail system or answering machine concerning an aspect of your treatment or reminding you of an appointment.
- We will share your PHI with third party “business Associates” that perform various activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your PHI, we will have a written contract that contains terms that will protect the privacy of your PHI.
Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object
We may use or disclose your PHI in the following situations without your consent or authorization.
These situations include:
- Required by law: We may use or disclosure your PHI to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.
- Public Health: We may disclose your PHI for public health activities an purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your PHI, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.
- Communicable Diseases: We may disclose your PHI, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
- Health oversight: We may disclose to a health oversight agency for activities authorized by law such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
- Abuse or Neglect: We may disclose your PHI to a health authority that is authorized by law to receive reports on child abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
- Food and Drug Administration: We may disclose your PHI to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biologic product deviations, track products; to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.
- Legal Proceedings: We may disclose PHI in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process. Law Enforcement: We may also disclose PHI, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include:
- Legal processes and otherwise required by law
- Limited information requests for identification and location purposes
- Pertaining to victims of a crime
- Suspicion that death has occurred as a result of criminal conduct
- In the event that a crime occurs on the premises of the practice
- Medical emergency (not on the Practice’s premises) and it is likely that a crime has occurred
- Coroners, Funeral Directors and Organ Donation: We may disclosure PHI to a coroner or medical examiner for identification purposes, determining cause of death or for one coroner or medical examiner to perform other duties authorized by law. We may also disclose PHI to a funeral director, as authorized by law. In order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death.
- Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your PHI.
- Criminal Activity: Consistent with applicable federal and state laws, we may disclose your PHI, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
If you are not present or able to agree or object to the use or disclosure of the PHI then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, on the PHI that is relevant to your health will be disclosed.
- Others Involved In Your Healthcare: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your PHI that directly relates to that persona’s responsibility for your care of your location, general condition or death. We may use of disclose your PHI to an authorization public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
- Emergencies: If your physician or another physician covering for the practice is required by law to treat you and the physician has attempted to obtain your consent but is unable to obtain your consent, he/she may still use or disclose your PHI to treat you.
- Communication Barriers: We may use and disclose your PHI if your physician or another physician in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using judgment, that you intend to consent to use or disclosure under the circumstances.
- Military Activity and National Security: When the appropriate conditions apply, we may use or disclose PHI of individuals who are Armed Forces personnel
- For activities deemed necessary by appropriate military command authorities
- For the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits
- To foreign military authority if you are a member of that foreign military services. We ay also disclose your PHI to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
- Worker’s compensation: Your PHI may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally-established programs. Inmates: we may use or disclose your PHI if you are an inmate of a correctional facility and your physician created or received your PHI in the course of providing care to you.
- Required Uses and Disclosure: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164/500et. Seq.
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Patient Information
