message and we will provide enough medication until your next visit. Do not rely on your pharmacy to contact us. Please give

72 business hours notice for medication refills. Please state the name of the pharmacy, medication needed, your name and date of birth.

Refills are not processed on Saturday or Sundays. You must call the office directly at 508-719-9653 or message through the OhMD application to request your refills.

You are signing this form stating that you understand that you will only receive psychiatric medications from this practice. You are

signing that you will not be obtaining new psychiatric meds or refills from other prescribers (both narcotic and non-narcotic), unless

you inform your provider that you are terminating services with your prescriber. This policy is to ensure your safety and best clinical

practice. If you are on a controlled substance, your prescriber may have you sign a controlled substance agreement. If you do not

follow this agreement, it is grounds for termination from this practice.

CANCELLATIONS OR RESCHEDULING

We require 48-hour notice for cancellations or rescheduling an appointment. You may be subject to a $100 fee for a missed

appointment or cancellation of less than 48 hours. Please call or text the office to change or cancel your appointment. If you miss more than 2 medication management appointments, it is difficult for our prescribers to provide safe care for you or your family member. We may need to discuss termination of medication management.

EMERGENCIES

For true medical or psychiatric emergencies, you should go to the emergency department or crisis center closest to you and have

the personnel contact your provider. Contact between appointments is reserved for emergency circumstances. Any clinical

communication that is not emergent will be addressed at your next appointment. Please make an appointment with your provider if

you need answers before your next visit. Concerns raised that require clinical assessment are not appropriate for a quick response

via email or text. Email and text will not be a communication tool to make treatment changes or voice concerns. Please schedule an

appointment to discuss your concerns at the following link: https://d2oe0ra32qx05a.cloudfront.net/?practiceKey=k_525_114354

PAYMENT

Payment is due at the time of the visit for copays and/or out of pocket expenses. Payment can be made by cash, check, health

care savings accounts or credit card. By signing this form, you give permission to clear balances upon time of service. If you have

changes to your credit card on file, please update your information by calling the office and a new form will be emailed and texted to you. If you have an outstanding balance, you must

remit payment before scheduling your next visit with your clinician. The billing office number is 508-456-8070 for your billing questions and payment options.

All co-payments must be made at the time of the service by cash, check or credit card. A bill for services (minus the copayment) will be

sent directly to your insurance company. If you have a secondary insurance that your provider does not take, you are still

responsible for the primary insurance’s copay.

I acknowledge that I have read this policy and that I am responsible for fees that are not covered by my insurance company. I

approve payments to be remitted from the listed credit card on file.

All visits are required to have an updated credit card on file for payment at time of

service. If a credit card is not on file, your appointment will need to be rescheduled.

DOCUMENTATION

The staff at Harborview Behavioral Health may use an AI scribe to help alleviate administrative burden and improve clinical documentation. We want the care that we provide to be primarily patient focused during the visit and this helps us accomplish that goal. The AI tool listens to the visit and generates a structured draft of the clinical note. Your provider then reviews, edits and finalizes to ensure accuracy before signing. The AI tool is not used for clinical decision making or diagnoses. The systems we use are HIPPA compliant to protect your data. Participation is voluntary and you may opt out any time. This will not negatively impact the quality of your care.

patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists,

and/or subspecialists. The information may be used for diagnosis, therapy, follow up and/or education, and may include any of the

following:

• Patient medical records

• Medical images

• Live two way audio and video

• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification

and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

• Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician

obtains test results and consults from healthcare practitioners at distant/other sites.

• More efficient medical evaluation and management.

• Obtaining expertise of a distant specialist.

POSSIBLE RISKS

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not

be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical

decision making by the physician and consultant(s);

• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;

• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information;

• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reaction or

other judgment error.

BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and

that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities

without my consent,

2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at

any time, without affecting my right to future care or treatment,

3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction,

and may receive copies of this information for a reasonable fee,

4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more

of these at any time. Erin Emerson, PMHNP-BC, has explained the alternatives to my satisfaction,

5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical

practitioners who may be located in other areas, including out of state.

6. I understand that it is my duty to inform Erin Emerson, PMHNP-BC of electronic interactions regarding my care that I may

have with other healthcare providers.

7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be

guaranteed or assured.