SOHOMD PRACTICE AGREEMENT

SohoMD FINANCIAL POLICY

It is our policy to require all patients to provide credit card information at the time of booking an appointment. You will be responsible for all charges incurred, including those amounts not paid by your insurance company. Predetermined fees associated with an appointment are required before time of service. If you do not have health insurance or have health insurance coverage with a plan we do not participate with, you will be required to pay for all services in full prior to the time of visit. For minor patients, the adult accompanying the patient is responsible for payment of the visit and related procedures. We can help prepare a statement for you to attach to your insurance claim for payment processing. Your insurance company should send its payment directly to you.

We accept Visa, Mastercard, American Express, and Discovery, we do not accept checks or cash. PLEASE NOTE: You may use an HSA payment card as your primary payment method on file; however, you must also provide a credit card as your backup payment method. Your credit card information will be held securely. When payments are due, Soho Medical Doctors, PLLC, Soho Medical Doctors California, and/or other affiliated entities (hereinafter “SohoMD”) will collect payments up to one business day prior to your scheduled appointments. It is your responsibility to keep your credit card information updated. Charges that fail to process or are denied by your credit card company will still remain your financial responsibility and may be subject to late fees.

You must present us with your most current health insurance card and a valid government issued photo ID at the time of the appointment. It is your responsibility to notify our office immediately of any changes to your insurance. As a courtesy, we will bill the fees of our services to your insurance plan provided that we participate with your health insurance plan and the service is covered under your plan. It is your responsibility to check with your health insurance carrier whether specific services or procedures are covered under your plan and to understand any policies they may have regarding your coverage of benefits. If your insurance requires you to have a preauthorization or referral to be seen in our office, you must provide these prior to your first appointment. 

If there is a remaining, unpaid balance on your account after your health insurance company has paid its portion, we will charge the remaining balance to your credit card and then send a copy of the charges to you. The services performed include assessing/addressing your diagnoses as well as a psychotherapy session. Each visit and service may vary depending on your needs. Additionally, our charges are based on contractual rates from the insurance company, and these can vary throughout the year based on the visit type. For specific information relating to the portion paid by your insurance, please refer to the Explanation of Benefits (EOB) that your insurance company is required to send you. Only your insurance company is responsible for determining your portion of the balance on the Explanation of Benefits form. In the event your health plan determines that a visit or service we already provided is not covered, declines payment for visits and services, or fails to pay, you will be responsible for payment in full and your credit card will be charged for the same. 

No Surprises and Right to a Good Faith Estimate. You understand and agree to pay for SohoMD services if you are not enrolled in a health benefits plan or choose to self-pay for any reason. You have been informed of the right to receive a Good Faith Estimate for the total expected cost of services. A Good Faith Estimate is available by messaging/calling SohoMD. If you receive a bill that is at least $400 more than the Good Faith Estimate, you have the right to dispute the bill by messaging/calling the SohoMD. For more information regarding a Good Faith Estimate, please message SohoMD via your patient portal access or call 212-369-6757.

By clicking the “I Agree” button, you acknowledge that you have carefully read and agree to the payment terms detailed above and that you authorize SohoMD to keep your credit card information on file and to charge the credit card for all amounts you owe to SohoMD. 

APPOINTMENT CANCELLATION, LATE, AND NO-SHOW POLICY

You will be charged $150* for missed appointments, e.g. appointments that are not cancelled 24 hours in advance (i.e. for Monday appointments, you must cancel by the appropriate time the preceding Sunday).

THERAPY: In the case that you are late for your full scheduled session, you may be subject to a $60 late fee in addition to your insurance responsibility. In the case that you are more than 25 minutes late and/or do not show up to your scheduled appointment, you may be subject to the full no show fee of $150.

MEDICATION MANAGEMENT: In the case that you are late for your 20 minute session, you may be subject to a $60 late fee in addition to your insurance responsibility. In the case that you are more than 15 minutes late and/or do not show up to your scheduled appointment, you may be  subject to the full no show fee of $150.

If you miss or “late” cancel two sessions, your provider may discharge you from their service. If at any time you want to discuss your financial obligations with us, we will be happy to make an appointment for you with a SohoMD administrator.

* Certain providers have lower or higher cancellation rates, but you would be made aware ahead of time.

An assessment can take from one to four appointments, and these sessions will be considered an evaluation until you are accepted as a patient at the practice.

By clicking the “I Agree” button, you acknowledge that you have read, understand, and agree to SohoMD’s Appointment Cancellation, Late, and No-Show Policy.

SohoMD ADMINISTRATIVE FEES

In an effort to offer you the most value and the highest quality of clinical services, we charge additional administrative fees for certain non-clinical services*. Therefore, you (or your authorized representative) may incur, and are responsible for the payment of, certain additional administrative fees, as follows:

*Please note that we require at least 1-2 weeks to attend to administrative requests, so please account for this timeframe when deciding when to submit your request. 

**Fees may differ depending on state 

By clicking the “I Agree” button, you acknowledge that you have  read, understand, and agree to SohoMD’s Administrative Fees Policy.

SohoMD REFILL POLICY

Medication refills are fulfilled at the discretion of your provider. Patients receiving refills must be seen by SohoMD prescribers for regular monitoring and follow-up. Refill requests will not be approved if the patient has not been seen by one of our prescribers within the last two months (one month for controlled substances). Refill requests will not be honored without a follow-up appointment scheduled with a prescriber. 

When requesting a refill, you can do so by calling the office or reaching out via our secure platform. We require at minimum three business days to attend to refill requests, so please account for this timeframe when deciding when to request your refill.

By clicking the “I Agree” button, you acknowledge that you have read, understand, and agree to SohoMD’s Refill Policy.

SohoMD NOTICE OF PRIVACY PRACTICES 

Your health information includes information created in the course of providing you with treatment and in billing for those services. In general, we will not release your personal health information to anyone, including your spouse/partner, unless you provide consent in writing. We will only share your medical records pursuant to your consent and/or in accordance with HIPAA and/or other laws governing such disclosures. 

Your health information may be shared if required or allowed by local, state, and federal law, including but not limited to matters of: public health, public safety, abuse, neglect, and court proceedings. 

Your health information may be shared for the provision, coordination, or management of your health care and related services by one or more health care providers, including consultation between providers regarding your health care and referral of your health care by one provider to another.

Your information may be shared to evaluate practitioner or provider performance, or to educate healthcare professionals. 

Your health information may be shared with business associates assisting us with business operations. All of our business associates are required to protect your health information. 

IN ORDER TO PROTECT THE PRIVACY OF OUR PRACTITIONERS AND PATIENTS, YOU AGREE NOT TO PHOTOGRAPH OR RECORD, VIA AUDIO, VIDEO AND/OR ANY OTHER MEANS, YOUR MEDICAL SESSIONS, WHETHER SUCH SESSION IS IN-PERSON OR VIA TELEMEDICINE, OR OTHER PATIENTS AND/OR SOHOMD’S OFFICES.

By clicking the “I Agree” button, you acknowledge that you have read, understand, and agree to SohoMD’s Notice of Privacy Practices and that you authorize SohoMD to release/share your patient health information for the purposes outlined above. You also authorize SohoMD to obtain your protected health information from other providers, including your medication history (e.g., via Surescripts).

SohoMD TELEMEDICINE INFORMED CONSENT 

NATURE OF TELEMEDICINE: Telemedicine provides psychiatric and/or therapy services using interactive audio, video and/or text conferencing tools in which the practitioner and the patient are not at the same location. Telemedicine will allow the patient to receive care without the need to visit the office. 

MEDICAL INFORMATION & RECORDS: All existing laws regarding access to medical information and disseminating medical records apply to care via Telemedicine. 

PHYSICIAN CHOICE OF CARE: The use of Telemedicine is determined by the provider. 

RIGHTS: I have the right to withhold or withdraw my consent to the use of Telemedicine at any time during the course of my care in writing. Alternatives to Telemedicine include traditional face-to-face sessions. 

CONFIDENTIALITY: Reasonable and appropriate efforts have been made to eliminate any confidentiality risks associated with Telemedicine. All confidentiality protections that exist under federal law apply to information disclosed during Telemedicine sessions. 

POTENTIAL RISKS: Potential risks include, but may not be limited to: information transmitted may not be sufficient (poor resolution of audio and/or video); delays in medical evaluation and treatment due to deficiencies or failure of the equipment; security protocols can fail, causing a breach of privacy; and a lack of access to all the information available in a face-to-face visit may result in errors in medical judgment. In the event that you are mentally compromised, due to the variability of patient location during Telemedicine, emergency services may fail to locate and treat you. In order to assist your emergency contact or emergency service providers, SohoMD will require you to identify your physical location prior to commencement of each Telemedicine session. 

By clicking the “I Agree” button, you acknowledge that you authorize SohoMD to use Telemedicine in the course of your diagnosis and treatment. 

SohoMD COMMUNICATION VIA EMAIL AND TEXT MESSAGES

Please be aware that emailing and text messaging with SohoMD practitioners and staff may not be the most secure means of communication, may not be HIPAA compliant and may compromise your confidentiality. However, we realize that many of our patients prefer to communicate via email and text message because it is a quick and convenient way to convey information. Therefore, in addition to email communications via Gmail, SohoMD provides for secure HIPAA compliant messaging. Such communications may include the status of a patient’s appointment or membership in any of our subscription services or billing matters, which may or may not contain protected health information. SohoMD may also use patient email addresses for informational communications (e.g., newsletters, service and products updates, etc.) and to conduct patient surveys for SohoMD's quality assessment and improvement purposes only. Such informational and survey emails shall be conducted via SohoMD's HIPAA compliant third- party vendor(s) (e.g., SimplyCast, Hubspot, etc.) in accordance with Privacy Policy and Terms of Use provided by such vendor(s). You can unsubscribe from such emails at any time (using the link at the footer of the emails you receive) and you may stop participating in any survey you start at any time. We will not otherwise distribute or sell your email address. Nonetheless, we strongly suggest that you exercise caution and only communicate through a private device that you know is safe and technologically secure (e.g., has anti-virus protection, is password protected, not accessing the internet through a public wireless network, etc.). As always, if you have an emergency, call 9-1-1.

By clicking the “I Agree” button, you acknowledge that your communications with SohoMD via unencrypted emails and text messages constitutes your consent to communicate via such means, and you further authorize SohoMD to send emails, including informational text messages that may include unencrypted protected health information.

SohoMD GROUP THERAPY GUIDELINES AND RULES

If you are a participant in any group therapy services provided by SohoMD, you agree to the following guidelines and rules:

Confidentiality and Privacy. You have the right to confidentiality and privacy in connection with group facilitators and other group members. Confidentiality within the group setting is a shared responsibility of all members and facilitators. While group facilitators may not disclose any client communications or information except as provided by law, group members’ communications are not protected. As such, confidentiality within the group setting is often based on mutual trust and respect. Nevertheless, by participating in group therapy, you hereby agree to strict compliance of the following rules:

• As a member of this group, you agree to not disclose to anyone outside the group any information that may help to identify another group member. This includes, without limitation, names, physical descriptions, and specifics regarding any content of interactions with other group members.
• You shall not engage in discussion of group issues outside of group. 
• You agree to participate in each session yourself and by yourself (i.e., you shall not have any other individuals appearing in your stead or present with you during a session, unless specifically authorized by SohoMD). 
• You may not use drugs or alcohol before or during group sessions.
• You agree not to photograph or record, via audio, video and/or any other means, your group sessions, the group facilitator or other patients.

Security of Your Personal Information.  YOU UNDERSTAND AND HEREBY ACKNOWLEDGE THAT USING ANY INTERNET-BASED SERVICE CARRIES INHERENT SECURITY RISKS, SUCH AS DATA BREACHES, THAT CANNOT BE 100% PREVENTED. SohoMD employs reasonable, HIPAA compliant, security measures designed to protect the security of information submitted through its services. Confidentiality of audio and video communications in individual and group therapy is protected by encryption and on a secure site. However, the security of information transmitted through the Internet can never be guaranteed. To protect you and your personal information we may suspend your use of SohoMD services, without notice, pending an investigation, if any breach of security is suspected.

Your Responsibilities. Group members are responsible for maintaining the security of any password, user ID or other form of authentication involved in obtaining access to password protected or secure areas of any of the online services offered by SohoMD. Access to and use of password protected and/or secure areas of SohoMD's services are restricted to authorized users only. It is your responsibility to choose a secure location to interact with technology-assisted media and to be aware that family, friends, employers, co-workers, or other third-parties could either overhear your communications or have access to the technology that you are interacting with.  You should only communicate through a computer or device that you know is safe (e.g., has a firewall, anti-virus software installed, is password protected, not accessing the internet through a public wireless network, etc.).  

By clicking the “I Agree” button, you acknowledge that you have read, understand, and agree to SohoMD’s Group Therapy Guidelines and Rules.

SohoMD ALTERNATIVE MEDICINE/SUPPLEMENTS INFORMED CONSENT 

It is my understanding that SohoMD may use “alternative” (a.k.a complementary, functional, integrative, holistic, non-traditional, biomedical) care methods including, without limitation, nutritional supplementation, herbal and homeopathic supplements, compounded medications including vitamin injections, homeopathic patches, compounded hormones, as well as alternative diagnostic testing methods to evaluate for food sensitivities, intestinal pathogens, metabolic imbalances, and heavy metal exposure.

I understand that SohoMD may employ interventions (treatment and/or testing) that may not always be considered “Evidence Based Medicine” (EBM) by some in the traditional medical community. Evidence-based medicine relies heavily on peer-reviewed research and clinical trials. However, not everything in “alternative” medicine can be deemed EBM from a traditional medicine standpoint as it relies on a clinician’s clinical experience with a particular therapy or hasn’t been fully funded or peer reviewed through research. This doesn’t mean therapies and testing that are not viewed as EBM are not effective or dangerous, but provides other options for health improvement. I agree that there are various definitions of “Evidence Based Medicine” and oftentimes they are too constrictive for my personal health pursuits and I wish to broaden the therapeutic and diagnostic options for myself/my child. 

I understand that these “alternative” methods under some circumstances could aggravate pre-existing conditions, and produce a range of side effects, such as allergic or hypersensitivity reactions to botanical remedies, nutritional supplements (which can come from plant, animal, mineral and other sources), and medical foods. Under rare conditions, severe illness could result. I willfully choose to explore this expanded approach for myself or my child to uncover and address therapeutically in order to help overcome my (or my child’s) health issues. 

I fully understand that botanical and homeopathic remedies, nutritional supplements, and medical foods that may be suggested, are often considered safe when taken as instructed in the practice of “alternative” medicine. I am aware that it is extremely important that I follow the suggested dosing when taking botanical remedies, nutritional supplements, hormones, and medical foods, etc. because some items may be toxic when taken in large doses. I understand that all these substances need to be prepared and consumed according to the instructions provided orally and/or in writing. Some preparations may have an unpleasant smell or taste. Some products may be inappropriate during pregnancy or prior to surgery, and I will immediately notify the doctor if I become aware that I am pregnant or am planning a surgical procedure. Because of the possibility of adverse drug-herb interactions, I agree to inform the doctor of all drugs – prescription and recreational – and herbs I am currently taking.

I agree to maintain my own primary care physician, or my child’s pediatrician (primary care doctor) with the understanding that SohoMD does not provide primary health care or after hour’s coverage for emergencies. 

I understand and desire to have SohoMD provide its interpretation skills for my or my child’s laboratory testing and provide its suggestions for health improvement for myself/my child, but that I am solely responsible for doing my own research, asking for second opinions from other health professionals if I choose, and sharing information with my or my child’s personal primary care doctor before implementing any diet, nutritional supplements or lifestyle change suggestions.

Any application of suggestions set forth via my consultations with SohoMD for my personal health care or my child’s health care such as the use of supplements, herbs, dietary changes, medications, and/or lifestyle changes is done so at my sole risk and responsibility, and I understand that SohoMD does not provide a guarantee of cure or of any health results. 

By clicking the “I Agree” button, you acknowledge that you have read and understand all of the foregoing regarding “alternative” medicine options that may be provided by SohoMD in the course of your care and treatment. 

It is your duty to know your insurance policy.  To obtain information about your policy, contact member services by calling the number on the back of your insurance card.

The services performed include assessing/addressing your diagnoses as well as a psychotherapy session. Each visit and service may vary depending on your needs. Your insurance company can also provide an explanation of benefits for services rendered. Please contact them for additional information.

QUESTIONS TO ASK YOUR INSURANCE PROVIDER

• Ask for CONFIRMATION that the services provided by SohoMD are covered under your plan.
• Ask whether your plan covers TELEHEALTH SERVICES (video/telephone sessions).
• Ask whether your plan is active for the date of service scheduled and whether it is this your PRIMARY INSURANCE.
• Confirm whether or not your plan covers OUTPATIENT MENTAL HEALTH SERVICES in an office setting. 
• Ask whether your plan has a copay, deductible or coinsurance and/or any accumulations towards the OUT OF POCKET or DEDUCTIBLE maximum.
• Ask whether referrals and Pre-certifications are required.

YOU are ultimately responsible for payment of all deductibles, co-payments, coinsurance amounts, AND for payment for all services you receive from SohoMD that are not paid for by your insurance provider.