Patient Policies | Tandem Telehealth

We welcome you to Tandem Telehealth Medical Group, PLLC (Tandem). We prepared the following information so that you may have a clear understanding of our policies concerning fees, insurance, and confidentiality. Tandem a group practice. You may be referred within the group for an appropriate health care provider according to your needs.

Appointment Cancellations, Rescheduling, No Show, Missed Appointments
Tandem will remind you of appointments via text messages and email prior to your session, unless you specifically request us not to do so. It is ultimately the patient's responsibility to keep track of their scheduled appointments. On the rare occasion that you do not receive a text or email reminder, you are still expected to be aware of your appointment and to appear on time. Appointments must be canceled 24 hours prior to your scheduled session. Appointments canceled less than 24 hours prior, or appointments that you do not attend will be charged a $100 NO SHOW fee or the full cost of the session. Insurance will not reimburse for missed appointments or late cancellations. Clients who show up more than 15 minutes late for 60-minute appointments or more than 10 minutes late for 30-minute appointments will be charged a NO SHOW for their session and the session will need to be rescheduled. NO SHOW FEES WILL BE CHARGED BEFORE THE CLOSE OF BUSINESS ON THE DAY OF THE MISSED APPOINTMENT TO THE CARD ON FILE. Communicated emergency exceptions will be honored and not incur a charge. In order to ensure that we are providing proper healthcare, patients are expected to appear to their scheduled appointments. If a patient has accrued 3 No Shows within a year, they will receive a discharge letter from the practice.

Provider Policy
We are a group of MD’s, Nurse Practitioners, Therapists, and other licensed mental health professionals. While we do our best to provide continuity of care by having you see the same provider for each appointment, there may be instances in which you will see a different provider.

Confidentiality Policy
Any confidential information you disclose to us during treatment, or any other confidential information we obtain while attending you professionally, shall be held in confidence unless you permit us to disclose such information or where we are required to disclose such information by law. By signing this contract, you are agreeing to the disclosure of confidential information to other physicians and therapists familiar with your case, where your provider decides it is clinically necessary or appropriate to do so. For example, if a physician or psychotherapist referred you to us for evaluation and treatment, your Tandem provider may communicate with that professional about your condition and treatment. Please tell us in advance if you want certain information withheld. Similarly, if we refer you to another physician or therapist within Tandem for treatment, that provider will have access to your records and may communicate with your prior provider(s).

Last Updated: December 1, 2023

I acknowledge the payment and insurance information set forth below and agree to pay for services rendered to me and/or facilitate the payment for services rendered to me by the providers affiliated with any of the behavioral health groups managed by Tandem Telehealth Medical Group, PLLC (Practice).

Payment of Fees: I agree to pay for charges for services as described in this agreement. I understand that:
a. Payment for sessions with providers affiliated with Practice is payable online through debit or credit card, unless otherwise established.
b. Payment for sessions is due after each session unless otherwise agreed upon and Practice will charge my card or bank account for my responsibility. Receipts may be provided at the time of the charge or on request.
c. I will be charged for sessions that I do not keep, unless I provide 24-hour notice to the Practice
d. If the credit card I provide is not in my own name, the person who is listed on the credit card will be entitled to receive receipts for services including the procedure codes and titles of appointments. If they inquire about further detail of my care, I will also be asked to sign a Release of Information providing them the requested information.
e. I understand that I cannot submit bills for cancellations to my insurance company or managed care plan
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Insurance and Managed Care Plans:
Practice participates in a number of insurance and managed care plans. If Practice participates in my plan, I agree to pay all applicable deductibles, co-payments, co-insurances and any other form of cost-sharing. If my insurance benefits run out, Practice will inform me of the ending date, and I will then be responsible for all charges dating from the end of insurance coverage. If my insurance plan denies the visit despite Practice following necessary procedures, I understand I may be responsible to pay in full for the service. You are responsible for the initial authorizations and for all fees that are applied to deductibles or non-covered services. You will never be charged for more than the contractual arrangement we have with your insurance company. Your acknowledgement below indicates your permission for us to release the necessary information to your insurance company to access your benefits and to charge your card on file for any balance not covered by insurance within 60 days.‍
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Assignment of Insurance Fees; Release of confidentiality for authorization of benefits and for clinical care:
I agree to allow my insurance plan or managed care plan to pay Practice directly, instead of paying me. In the event that my plan pays me directly, I will promptly turn the payment over to Practice unless I have already paid the charges myself. I authorize Practice to provide my insurance plan or managed care plan any information reasonably required to obtain insurance benefits and authorization for services. I authorize Practice to obtain at any time during my treatment here, any and all relevant clinical information from clinicians and facilities that have treated me and to furnish relevant clinical information to providers who will continue to treat me. I will indicate in writing any exceptions to this.
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Fee Schedules and Related Policies
          a. Psychiatry Fees (All ages)
                i. MD/DO Initial Evaluation $500
                ii. MD/DO Follow-Up $200
                iii. APC/NP Initial Evaluation $300
                iv. APC/NP Follow-Up $175
          b. Therapy/Counseling (All ages)
                i. LPC/LMFT/LMHC Initial Evaluation or Follow up $120/53-60 mins
                ii. NP Psychotherapy $250/53-60 mins
                iii. MD/DO Psychotherapy $350/53-60 mins
         c. Other Fees (All ages)
                i. Telephone Requests: provider hourly rate prorated per 15 minutes
                ii. Record Requests: $50
                iii. Rx refills outside of appointment times $35
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               iv. Forensic Matters/Documents: hourly rate of $750 ($1000 for MD/DO)
         d. Telephone Requests: Clients in therapy may occasionally have the need for crisis intervention by telephone. Telephone charges are based upon the provider's standard fee per 45 minutes and prorated per minute. There is no charge for calls under 15 minutes concerning side effects of medications that you have been prescribed by one of our providers. However, if the medication call involves phoning in or otherwise reissuing a prescription, you will be charged. The on-call clinician will only provide enough medication through your regular clinician's next business day.
         e. Record Requests: We will make our best efforts to transfer records at your request free of charge. In cases where we incur costs in searching, handling, and copying medical records, we reserve the right to charge a flat fee of $50.00 for each request to cover copying costs, mailing medical records for the patient or the patient's designated representative. If requested by the patient or the patient's designated representative, nothing herein shall limit a reasonable professional fee charged by a physician for the review and preparation of a narrative summary of the records.
         f. Prescription Refill Requests: The best time to get a prescription refill is at your appointment. Please note that our office only provides refills outside of an appointment when the patient calls our office directly. We do not provide refills from pharmacy requests. If you need to refill your prescription outside of an appointment, please contact our office. Please note that there is a fee (listed in this policy) for refills done outside of appointment times.
         g. Forensic Matters: The following are examples of exceptions to the Confidentiality agreement and fees in relation to Forensic Matters. 1.) If we assess that our patient is a clear and present danger to himself/herself or another person, appropriate others may be notified to prevent that occurrence. 2.) If there is reason to suspect that child or elder abuse has occurred, the law requires that it be reported to the proper authorities. 3.) In a legal proceeding, the Judge may order disclosure of information he/she feels would be necessary for the proper administration of justice. In certain cases, a Tandem provider may be willing to act as an Expert Witness in a court action involving a client. If you wish to engage the services of a clinician as an Expert Witness, you must read and sign a Tandem Witness Agreement that binds you to the payment for the clinician's time in preparing for court, appearing in court, preparing reports, communicating with attorneys, etc. Please discuss the possibility of court appearances with your doctor or therapist as far in advance as possible. In the event that a Tandem clinician is subpoenaed to appear in a court action involving the care that was delivered to you or to a family member, you will be charged the forensic hourly rate noted within this policy for court appearances with a minimum of three hours, even in the absence of a signed Expert Witness Agreement. Even if the subpoena is not issued by your attorney, but rather by an adverse party, you will be charged for and expected to pay the clinician's fee for these services. Please note that we do not participate in custody evaluations.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY

Last Updated: August 10, 2023

OVERVIEW

This notice will tell you about the ways Tandem Telehealth Medical Group, PLLC (“Practice,” “we,” or “us”) may disclose health information about you and will also describe your rights and certain obligations that we have regarding the use and disclosure of your health information. Tandem is a behavioral health group that is operated across multiple legal entities which are referred to by the HIPAA Privacy Rule as an "organized health care arrangement." Tandem has relationships with the providers listed on this website and provides services via telehealth and at the service delivery sites of the providers listed on this website. Tandem's legal entities share protected health information with each other, as necessary to carry out Tandem's treatment, payment and health care operations. All of the legal entities that comprise Tandem agree to comply with the terms of this Notice of Privacy Practices.

We are required by law to: make sure that health information that identifies you is kept private; give you this notice of our legal duties and privacy practices with respect to your health information; notify you following a breach of your unsecured protected health information; and follow the terms of the notice that are currently in effect. Although this notice is being provided to you electronically, and by signing an acknowledgment of receipt of this notice, you consent to the provision of this notice electronically, you have the right to request a paper copy of this notice. We reserve the right to change our privacy practices and the terms of this notice at any time. You may obtain a copy of the revised notice on this website. This notice is effective as of July 21, 2023.

HOW YOUR INFORMATION IS USED

We may use and disclose your health information for the purposes of providing services and quality care. For the avoidance of doubt, providing treatment services, collecting payment and conducting healthcare operations are all necessary activities for quality care. State and federal laws allow us to use and disclose your health information for these purposes.

Here are some helpful examples, but this list is not exhaustive:

Using your information for providing treatment. For example, If your treating provider cannot prescribe medications but wants to refer you to a prescriber in your insurance network, he or she may use your health information for the purpose of referring you to a prescriber who is affiliated with the Practice.

The Practice or its business associates may use and disclose health information in order to verify your insurance and coverage.

Example of using and disclosing your health information for collecting payment.

The Practice or its business associates will submit claims for reimbursement to your insurance company in order for them to pay us for the services we provide to you, which requires using your health information.

Examples of using and disclosing your health information for healthcare operations.

The Practice or its business associates will use and disclose your health information for the review of treatment procedures, and may use it to review documentation to ensure provider compliance.

For uses and disclosures for purposes other than treatment, payment and operations, we are required to have your written authorization, unless the use or disclosure falls within an exception, such as those described below. Most uses and disclosures of psychotherapy notes (as that term is defined in the HIPAA Privacy Rule), uses and disclosures for marketing purposes, and disclosures that constitute the sale of Personal Information require your authorization. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we may have already taken any action in reliance on your authorization.

DISCLOSURES THAT CAN BE MADE WITHOUT AN AUTHORIZATION

Emergencies. Sufficient information may be shared to address an immediate emergency you are facing.
Judicial and Administrative Proceedings. We may disclose your personal health information in the course of a judicial or administrative proceeding in response to a valid court order or other lawful process, including if you were to make a claim for Workers Compensation.
Public Health Activities. If we felt you were an immediate danger to yourself or others, we may disclose health information about you to the authorities, as well as alert any other person who may be in danger.
Child/Elder Abuse. We may disclose health information about you related to the suspicion of child and/or elder abuse or neglect.
Criminal Activity or Danger to Others. We may disclose health information if a crime is committed on our premises or against our personnel, or if we believe there is someone who is in immediate danger.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These activities might include audits or inspections and are necessary for the government to monitor the health care system and assure compliance with civil rights laws. Regulatory and accrediting organizations may review your case record to ensure compliance with their requirements. The minimum necessary information will be provided in these instances.
Business Associates. The Practice may disclose the minimum necessary health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, the Practice contracts with a vendor for filing claims with insurance companies. In the process of filing claims, that organization will come into contact with your information. We also contract with a vendor that collects and manages internet or other electronic network activity on our sites and services and internally encodes it so that we can determine and manage information that might be health information. All of our business associates sign agreements to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Research. Under certain circumstances, we may use and disclose health information for research. We may permit researchers to look at non-identifying information to help them plan research projects.
Marketing. We may send you newsletters or information about services we provide in which we feel you might be interested. You may at any time request that your name be removed from our mailing list.
Scheduling appointments. We may email or call you to schedule or remind you of appointments.

YOUR INDIVIDUAL RIGHTS

Right to Inspect and Copy. You have the right to look at or get copies of your health information, with limited exceptions. Your request must be in writing. If you request a copy of the information, a reasonable charge may be made for the costs incurred.
Right to Amend. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We have the right to deny your request under certain circumstances.
Right to an Accounting of Disclosures. You have the right to receive a list of instances in which we have disclosed your health information for a purpose other than treatment, payment, or health care operations. To request an accounting of disclosures, you must submit your request in writing to the Privacy Officer. Such accountings remain available for six years after the last date of service at the Practice.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose about you. For example, you could ask that we not share information with an insurance company, in which case you would be responsible to pay in full for the services provided. While you are in treatment, a written request should be made with your therapist. To request a restriction after therapy is completed, you must make your written request to the Privacy Officer. We are not required to agree to your request, but we will consider the request very seriously. If we agree, we will abide by our agreement unless the information is needed in an emergency or by law.
Right to Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you may ask that we contact you only by mail or at work. You must make this request in writing and it must specify the alternative means or location that you would like us to use to provide you information about your health care. We will make every attempt to accommodate reasonable requests.
Right to File Complaints. You may complain to us and to the Secretary of Health and Human Services if you believe your privacy rights have been violated. You may file a complaint with us by contacting the Privacy Officer at compliance@tandemtelehealth.com or (804) 332–6061. You will not be retaliated against for filing a complaint. You may also contact the Privacy Officer for further information about this notice.

EMAIL AND TEXT MESSAGES

Some of our patients prefer to communicate with their provider via email or text message. Email and text messages have inherent privacy and security risks, and you should be aware of those before using emails and text messages. Errors in transmission or interception of messages can occur. Your email or text message is not a secure communication between you and your treating provider. At your health care provider’s discretion, your email or text message and all responses may become part of your medical record. Additionally, for urgent or an emergency situation, you should not rely on email communication with providers affiliated with the Practice. In those situations, you should call 911.