A Copy of the SOMH Office Policies is available for download at the bottom of the page.
OFFICE POLICIES / TREATMENT AGREEMENT
Our mission is to provide you with personalized attention and care in a warm and friendly environment. We maintain our schedule by only booking one appointment at any given time allowing the doctor and nurse practitioners (NPs) to spend more time with you addressing your concerns and as this helps minimize any wait that you might experience. We are able to provide this by asking that you abide by our office policies and treatment agreement. We recognize that healthcare is expensive, insurance requirements are frustrating, and discussing payment arrangements when you don’t feel well may be unpleasant. While we will make every effort to obtain appropriate payment from your insurance carrier, payment for services rendered is ultimately your responsibility.
Notice of Privacy Practices and Confidentiality
All information is guarded by strict confidentiality and in accordance with HIPAA regulations. We require your written consent in order to release/obtain information. By completing this form you acknowledge that you were provided a copy of, or electronic access to, the Notice of Privacy Practices. A copy of our Privacy Practices is available on our website stateofmindhealth.com and information release forms can be obtained as needed onsite Office Hours Our office hours are subject to change, but are generally Monday thru Thursday 9:00 am to 4:00 pm and Friday 9:00 am to 1:00 pm.
Patients are seen on an appointment-only basis during office hours. We do not offer walk-in appointments, but will try to accommodate your scheduling needs whenever possible. Please call our office during business hours to schedule an appointment or request an appointment via the patient portal. Urgent visits to see nurse practitioners can be scheduled at the beginning of the next business day prior to 12PM.
We have an automated service that will provide you with a reminder email prior to your scheduled appointment. These reminders are a courtesy and we are not responsible for appointments missed due to incorrect contact information or nonreceipt of a reminder email. It is the patient's responsibility to keep the scheduled appointments or reschedule / cancel the appointment with 48 hours notice for new patients and 24 hours notice for existing patients.
All patients are strongly urged to call 911 or go to the nearest hospital emergency room should they become acutely symptomatic or experience suicidal or homicidal thoughts. We also would encourage anyone requiring urgent assistance to contact the Rockland County Behavioral Response Team at 845-517-0400. This is a 24 hours per day emergency service that is free of charge and is staffed by trained mental health professionals. Please also contact our office after seeking emergency care / treatment on the next business day.
Contacting Our Office
Questions about your treatment or medication should be done face-to-face during your next visit. Our providers offer telemedicine through a HIPPA compliant website that is available for urgent situations. If you need to report medication effects or changes in your symptoms prior to your next visit, you must explain in detail your situation when you contact our office and the front office will do their best to assist you.
Referrals and Authorizations
If your plan(s) require a referral from your primary care physician, please make sure one has been provided prior to your appointment.
Prior Authorizations for Medications
Some insurance plans require prior authorization for medications that are prescribed to you. (Specifically ADHD medications and newer brand medications) If your insurance plan requires a prior authorization, please ask your pharmacy to fax the required information to our office 845-653-7301. It is ultimately up to your insurance carrier to determine coverage for medications. The processing time for prior authorizations varies; in some cases it may take 1 to 2 weeks. Whenever possible we will provide samples of your medication until your insurance coverage is approved. If you have questions about your pharmacy benefits please contact your insurance carrier directly. Contacting our staff regarding a medication prior authorization must be done using our patient portal or by leaving a detailed message.
We currently do not accept insurance at this moment. If your insurance coverage includes out-of-network care, we are more than happy to create a superbill for you to receive reimbursement.
Payment for Services
We accept cash, check, and most credit cards and payments can be made using our secure patient portal. We are unable to accept Flex Spending cards, but can provide you with a receipt so that you may seek reimbursement from them.
We will securely store your credit card information and use it to automatically charge any “No Show” fees, “Membership” fees, or unpaid “Past Due Balances” on your account. Should you wish to make alternative payment arrangements or have any questions about your bill, you may address these by contacting our front office.
Past Due Balances
Balances that are not paid within 30 days from the date of service are considered past-due. Balances that are not paid within 60 days of the date of service will be charged to your credit card on file and if the charge is declined will be forwarded to a collection agency. Collection agency and any associated legal fees may be added to the account. Patients with past-due balances will be required to make payment arrangements before additional services will be scheduled.
Bounced Check Fee
There will be a $25 fee automatically charged to your credit card on file for any bounced checks.
No-Show and Late Cancellation Fees
While we make every effort to maintain our daily schedule, unforeseen issues often arise and we may run behind schedule. We absolutely guarantee every patient their time with the Psychiatric Nurse Practitioner and will make every attempt to keep your wait to a minimum. In order to accomplish this we do not “double book” our appointments and every individual is provided with their own schedule time. To allow us to minimize your wait and schedule only one person to a time slot, we must charge a fee for individuals who do not show for their schedules appointment and do not provide sufficient notice for us to give your time to another person in need.
Missed appointment charge for an initial evaluation (48 hours notice required) $200
Missed appointment charge for a follow-up visit (24 hours notice required) $75
Completion of Forms/Paperwork
Our Nurse Practitioner's time is limited and below is the fee schedule that must be charge for the time required to meet your needs and to complete your documentation or letter. During the course of your treatment you may have paperwork you would like the Nurse Practitioner to prepare or would Nurse Practitioner to speak with a 3rd party on your behalf. Every effort will be made to complete your request in as timely a manner as possible. For any paperwork requests that are extensive in nature (for example, disability paperwork) we ask that you speak with the front desk to make the necessary arrangements.
There will be a charge of $75 per 15 minutes required to complete your requested documents.
Phone Calls and Email
It is common to have questions for the nurse practitioners that you forgot to ask during your session or to experience something that you would like to discuss with the Nurse Practitioner. If these issues can’t wait until your next scheduled visit you can call our office to schedule an urgent visit in the next available time slot. Please let the front desk staff know what you are experiencing so we can determine if the problem can be addressed over the phone. Issues regarding your care (non-emergency side effects of medications or requests for medication adjustments) should be discussed in person during face-to-face visits.
If your issue requires a call to our office or is an emergency, you will need to state the nature of the call / emergency for us to prioritize your issue and so that the Nurse Practitioner can be informed in a timely manor. For all non-emergency office issues, our staff will do its best to help meet your needs during business hours.
The nurse practitioner takes responsibility for each patient they care for. To do so, an evaluation must take place during certain intervals and at a minimum, you must be seen at least one time every 3 months. If a required follow up is not made at the 3-month period you will no longer be considered an active patient / client of State of Mind Health Psychiatry NP, PLLC / Nechama Keller-Sabel PMHNP and we will no longer accept responsibility for your care.
Prescriptions: You have been prescribed enough medication to last until you will need to be seen again for further evaluation. The Nurse Practitioner is required to monitor your response to medication and it is your responsibility to schedule an appointment prior to running out of medication. Our schedule fills up quickly and we strongly recommend booking your follow-up appointment at the conclusion of each visit. A Short supply of medication that is needed once a visit is required will be refilled with a charge of $35.00.
As a courtesy to the transitioning patients of Madison Wellness, please ask the front office for the special fee schedule offered for continuation of your care.
Initial-New Patient Consultation/Evaluation (may involve 1-3 sessions) $400-450 Per Session
Evaluation/Management (E/M) 15 -30 min medication management $150 -$275 Per Session
Evaluation/Management (E/M)+Psychotherapy $375 Per Session Follow-up sessions (50min)
Extended consultation with patients, families, or professionals $400 / Hour
Refills or prescriptions made between appointments (1 week supply) $35
Calls/Phone Sessions/ Phone Consultations 10-15 minutes $125
Vitamin B12 Injection $35 Genetic Testing $75
A sliding fee schedule can be arranged for patients that require financial assistance.
AUTHORIZATION FOR TREATMENT
I hereby authorize State of Mind Health Psychiatry NP, PLLC to perform any and all forms of treatment, medication, and therapy that are indicated and in accordance with the Standards of Psychiatric Care. I hereby authorize State of Mind Health Psychiatry NP, PLLC to furnish information to the insurance carriers concerning my illness and/or treatment and hereby assign to the nurse practitioner all payment for medical services rendered to myself, the patient. I understand that I am responsible for any amount not covered by insurance and agree to the above office policies and financial agreement. By signing, I authorize treatment by State of Mind Health Psychiatry NP, PLLC and indicate my understanding of the Financial Policies, Treatment Agreement and the Authorization for Treatment.
Signature of Patient or Legal Guardian Date
Patient Name: Print