Independently Practicing Providers
I understand the provider practices with an association of independently practicing professionals which shares certain expenses and administrative functions under the name PCA Resources, Inc. While they share office space, this provider is a completely independent professional rendering clinical services and is fully responsible for those services. Clinical records are separately maintained, and other professionals cannot have access to them without your permission.

Nature & Purposes of Services
Services include psychiatric evaluation, diagnosis, and medication management. We will discuss benefits, risks, and alternatives to proposed medications, including the option of no medication. Medication does not replace psychotherapy; referrals can be provided as needed.

Risks & benefits
Benefits may include symptom relief, improved coping/relationships, and clearer understanding of strengths and needs. Risks may include side effects, interactions, allergic reactions, rare serious events, FDA boxed warnings where applicable, temporary increases in distress, recalling difficult memories, or changes in relationships or habits. Outcomes cannot be guaranteed.

Alternatives
Alternatives include self-help resources, support groups, therapy, community programs, and referrals to other clinicians.

Patient Responsibilities & Safety
Take medications only as prescribed; do not change doses without discussing with your prescriber. Keep all follow‑up appointments as directed. Tell your prescriber about all medications, supplements, and substance use (including alcohol/cannabis). If pregnant, planning pregnancy, or breastfeeding, inform us immediately to discuss risks/alternatives. Use caution with driving or hazardous tasks if a medication causes sedation or impairment.

Refill & Controlled‑Substance Policy
Refills are processed during business hours; please request at least 2 business days in advance. No early refills for lost/stolen/damaged medications except in emergency situations; secure storage is your responsibility. For controlled substances (e.g., stimulants, certain anxiolytics): one prescriber/one pharmacy; PDMP review; pill counts, or random urine drug screens may be required. Refills require appropriate follow‑up visits; missed appointments may delay or prevent refills.

Emergencies, After-Hours, and Termination
We do not provide 24/7 coverage. For urgent concerns, call 988 or 911 or go to the nearest emergency department. For non-urgent matters, call us at 479-443-5575. If a higher level of care is recommended, we will discuss referrals. We may transition or conclude services, with reasonable notice and subject to applicable law, when ongoing treatment is no longer clinically indicated or beneficial; when appointments are repeatedly missed or fees remain unpaid despite notice; or when conflicts of interest or boundary concerns arise. When clinically appropriate, we will provide information about alternative providers and community resources, though we cannot guarantee availability or acceptance.

You can review the Notice of HIPAA Privacy Practices at https://pca-nwa.com/hipaa

Confidentiality and Limits:
Although I am bound by ethical principles to keep information about you confidential, there are certain exceptions to these principles that you should understand prior to entering into the therapeutic relationship.
1. In a case of suspected child abuse, I am required to report this to the appropriate authorities even when this requires breaking confidentiality.
2. If, at some point, I believe that your child's life or someone else’s life is endangered, I may break confidentiality to warn or prevent harm to your child or another person.
3. If you are using a third-party payer (private insurance, managed health care, or Medicare), I may be required to submit reports or information, such as diagnoses, to obtain reimbursement from your insurer. If there are irresolvable difficulties in payment of fees, it may be necessary to turn account names over to an attorney or a collection agency.
4. Under some circumstances, such as custody and divorce litigation, records may be subpoenaed by a judge.
5. If you sign a release of information in order that I may speak or correspond with professionals with whom you have had previous contact, information about you or your child will be divulged with your consent.
6. If you are a legal minor (under age 18) or a person under the age of 21 (who is under the supervision of your parents), and you engage in behaviors that are seriously threatening your health and well-being, this information may be divulged. I will try to inform you of this decision before I do so.

Records, Access, and Retention:
We maintain a confidential clinical record (treatment notes, testing reports, communications, and administrative information) in an electronic health record (EHR). You may request access to your record as permitted by law and may request amendments. We maintain client records according to state record retention guidelines. Administrative fees may apply for copies, summaries, or disclosures.
Clinician psychotherapy notes: If a clinician keeps separate psychotherapy notes (kept apart from the EHR), these receive special protection under HIPAA and are generally not released without specific authorization.

By checking the box below, I indicate that I agree to authorize payment of insurance benefits to the service provider, authorize the release of any information necessary to process insurance claims, and accept payment responsibility of the portion of the bill which insurance does not cover.

Professional fees:
A current fee schedule is available upon request and may vary by clinician. Time spent outside sessions at your request (e.g., letters/forms, extended calls, portal messages, coordination with schools/providers and/or records preparation) that takes more than 15 minutes will be billed in 15 minutes increments at your clinician’s regular hourly rate. Legal matters (e.g., depositions, testimony, record reviews, travel) are billed at higher rates with minimum retainers.

Payment:
Payment (or known copay/coinsurance/deductible) is due at the time of service. Unpaid balances may lead to suspension of non-urgent services and may be referred to collections after notice.

Insurance:
If we are in network, we will bill your plan, and you are responsible for amounts your plan assigns to you. If we are out of network or you elect self-pay, you are responsible for full charges. Your plan may require diagnoses and clinical information to approve payment; denied claims become your responsibility. Upon request, we can provide a superbill to seek out of network reimbursement.

Good Faith Estimates (self-pay):
If you are not using insurance, you are entitled to a Good Faith Estimate of expected charges. This is an estimate, not a contract, and your actual needs may change. Ask us if you have questions or want a written estimate.

Scheduling, late arrivals, cancellations/no shows:
Please arrive on time. If you are late for an appointment, we may need to reschedule, and the full fee may apply. Appointments canceled with less than 24-hour notice or missed without notice may be charged a no-show fee of up to $150 (not billable to insurance). Repeated late cancels/no shows may result in termination of services with referrals offered.

Digital Communication:
You may receive non-clinical messages (e.g., scheduling reminders, rescheduling requests) by text/email. Email and text (if used) are for logistics only and are not appropriate for clinical content or emergencies.
Our patient portal is the preferred option for sending non-urgent messages and is a HIPAA secure method of communication. We generally reply within 1-2 business days and do not monitor messages after hours.

Telehealth:
Telehealth uses secure audio/video technologies to deliver care when in person visits are not feasible. By participating in telehealth, you acknowledge: (a) the need for a private location and reliable connection; (b) we must both be physically located in states where the clinician is permitted to practice; (c) rare technology failures and reduced nonverbal cues may affect care; (d) if the connection fails, we may switch to phone or reschedule; (e) no recording of sessions by either party without written consent.