Fee Agreement:

Hope and Wellness is a fee for service practice. All charges must be paid at the time of service. Fees may be paid by cash, check or credit/debit card. The preferred method of payment and what may be required by the provider is to pay via patient portal. 

 

I understand that should I accrue a debt equaling/more than $120.00 (not including what is owed by insurance) or is outstanding by 90 days or more I may not be able to be rescheduled until the debt is paid in full and this is my responsibility in the provider-patient relationship. Any outstanding debt more than 120 days will be eligible for submission to a collection agency

 

Insurance Claims:

Hope and Wellness will file insurance claims for selected policies/plans; these abilities may vary depending on provider. Filing a claim does not guarantee payment. You are responsible for paying all fees including unpaid/uncovered amounts by your insurance, co-pays, coinsurance, and deductibles. 

 

Please contact your insurance company and obtain the following information about your Outpatient Mental Health benefits.

 

Check Policy:

If your check is returned for insufficient funds, you authorize your account to be electronically debited or bank drafted for the full check amount plus applicable fees. Using a check is your acknowledgement and acceptance of this policy, its terms and conditions. Include on your check: Full name, address, and phone number.

If your check is returned as non-payable you will be charged a $35.00 returned check fee that will need to be paid prior to your next scheduled appointment. The clinic reserves the right to not further accept checks for any patients who have returned checks.

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Cancellations, Late Arrivals, and No Shows:

Cancellations: Appointments must be canceled at least twenty-four (24) hours prior to your appointment by calling, texting or emailing the clinic; The preferred method of communication will be designated by your provider. A minimum of $50.00 may be charged for sessions canceled less than 24 hours before your appointment. 

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Late Arrival: If you will be late for an appointment, it is your responsibility to inform the clinic as soon as you are aware you will be late. 

For appointments scheduled 30 minutes or more: You will be seen during the originally allotted time slot. You may be responsible for an additional charge of (no more than) $50.00 if your provider is not able to bill insurance for the original amount of time. 

For appointments scheduled for less than 30 minutes: Your appointment may be canceled based on the provider’s discretion. If canceled for this reason, you may be charged a minimum of $50.00. 

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No Shows: Attending all scheduled appointments with your provider is a crucial part of treatment. For sessions in which you do no show the provider you will be charge a no show fee based on occurrences. These fees will be applied to your account will have to be paid prior to your next scheduled appointment. The clinic reserves the right to charge you for your full visit and/or refer you out to another clinic should you continually fail to adhere to this policy.

• 1st Occurrence: $50.00

• 2nd Occurrence: $100.00

• 3rd Occurrence: $150.00

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Continued Offenses: A recurrence of at least three (3) inadequate cancellations, late arrivals, and/or no shows may result in termination of services and will be determined by your provider on a case by case basis.

 

Based on this policy, credit card information and authorization are requested.

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Medication Policy: 

Our APRNs are licensed advanced practice registered nurse and board certified psychiatric mental health nurse practitioner. As such, it is within their scope of practice to prescribe medications for managing various mental health conditions across the lifespan. They will do so based on extensive assessment and clinical judgment, guided by current research and evidence-based practice guidelines. They is under no obligation to continue medications prescribed by other providers. If taking medications that he/she deems inappropriate/unnecessary, you will be safely weaned off the medication to avoid withdrawal symptoms, although zero side effects cannot be guaranteed. Continuing certain medications against medical advice may result in referral to another provider.  

In addition to the above provide there is also other medical providers including board certified psychiatrist whose prescribing practices coincide with our APRNs.

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Refill Policy:

Hope and Wellness understands that there may be times where medications may warrant a refill without seeing a provider. If this situation should occur please call the office at (501) 653-7604 and speak to the front desk, or send a message through the patient portal. All refill requests will be completed within 1 week if requested Monday - Thursday. Refills requested on Friday, Saturday, or Sunday will not be processed for review until Monday, and will be sent for fulfillment. Hope and Wellness does not have an after hours prescription refill line to call. If you find yourself in a situation where you are out of medication and the clinic is closed, and the medication is vital to your mental health and/or well being please visit the nearest urgent care or emergency department. Should you take this step you understand that if any other provider prescribes controlled substances you are required to notify the office as soon as possible.​

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Hope and Wellness reserves the right to deny prescription refill requests and request patients come in for a medication review appointment.

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Confidentiality:

All information you share with Hope and Wellness will be kept protected and confidential. Your health records and health information will not be shared without your expressed written permission. The minimum necessary information will be provided to file insurance claims. We will take all reasonable measures to abide by the HIPPA guidelines. We are required by law to make a few exceptions to this rule: 

• Sharing your information will prevent harm to yourself or others.

• In the event of suspected abuse of a child, or an incompetent or elderly adult.

• If records are requested by subpoena or court order.

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Conduct:

While under the care of Hope and Wellness you should attempt to behave in a civil manner with all staff that are part of this psychiatric clinic or in the building of 1003 Schneider Drive, Malvern, Arkansas 72104. There is a low-tolerance for inappropriate behaviors, threats, etc., and should I not abide by this policy I may be discharged from care at the decision of my provider and the owner(s) of the clinic. Should this happen I understand that a referral will be sent on my behalf to a appropriate mental health clinic.

 

Participation in Treatment:

Participation in services with Hope and Wellness is voluntary. It is your right to question modalities of treatment, refuse treatment, seek treatment elsewhere, and/or terminate services at any time. Owner and operator, Schantz Flores, is a licensed and board certified psychiatric mental health nurse practitioner whose scope of practice includes psychotherapy and medication management. There may also be other medication providers that fall under the license of a APRN or MD, or a medical/nursing student in the process of receiving licensure (however the students will not be actually prescribing the medication). Therapy practices at Hope and Wellness may also be provided by licensed therapists with varying degrees and licensure; they will discuss their scope of practice with you, as well as their areas of expertise and certification in each case. Various methods will be incorporated to the extent that credible empirical evidence supports to be beneficial for treatment of specific mental health conditions. 

 

I understand that there may be time where my provider requires lab work or other diagnostic testing. This may include but is not limited to blood work, EKG, CT scans, pregnancy test and drug test.

 

While under the care of Hope and Wellness I understand that treatment, in most cases, requires adherence to both a medication regimen and psychotherapy modalities. I understand that it will be required of me while receiving care to participate in both, and that if I already have a therapy provider from another clinic I give permission for Hope and wellness to have full collaboration with them. I will be given a HIPPA release in order to do this and intend to sign.