Psychiatric Medication Management Consent and Information Form

Nystrom & Associates, Ltd.

Thank you for choosing Nystrom & Associates, Ltd. for your care. It is important for you to read each item carefully and initial in the space provided to the left each item. By initialing you are indicating you have read, and understand the content of each item. If you have any questions about the items below, please discuss with your provider at your appointment.

General:

Consent*

I am consenting to be evaluated to undergo possible medication treatment for my mental illness. Medication options will be discussed with your provider. Some of these options may include antidepressants, or psychotropic medications. I may also be recommended to participate in other forms of mental health care treatment.

Consent*

NAL does not offer after- hours services. If you have a concern, please contact us using FollowMyHealth or by calling your clinic. Your message will first be triaged through our nursing team who will contact you within one business day.

Consent*

If you have an emergency, such as severe suicidal thoughts, thoughts to hurt someone else, or a severe drug reaction, you should call 911, go to your local urgent care, or go to the emergency room.

Consent*

Legal guardians must attend all appointments with minors and adult patients who are not their own legal guardians for treatment to occur, unless exceptions have been approved by the Office Manager prior to the appointment.

Medication Refill Requests:

Consent*

You should contact your pharmacy or use FollowMyHealth first for all medication refill requests.

Consent*

Refill authorizations can take up to 5 business days.

Consent*

Controlled medication refills will not be authorized more than 3 days before they are due for refill. If you have questions regarding early refills, please speak with your provider.

Appointment Scheduling and Cancellations

Consent*

Appointments cancelled without a 24 hour notice may be assessed a fee up to $120.00.

Consent*

If you arrive late to your appointment, you may not be able to be seen and may be assessed a fee up to $120.00.

Consent*

If you miss 3 appointments in a 12 month period with your medication provider, we will end care with you.

Consent*

You may be able to schedule a same day or cancelation appointment if you 1). have missed your appointment, 2). need forms completed, or 3). have other treatment concerns.

Consent*

Many of our providers work with medical or nursing students. You should inform your provider if you do not want a student participating in your appointments.

Forms:

Consent*

Our providers require an appointment to complete any forms. Any forms needing completion should be dropped off at the front desk. Your provider will review the forms and notify staff how long to schedule your forms appointment for. Any forms completed outside of an office visit will be assessed a fee, requiring prepayment.

Laboratory & Psychological Testing:

Consent*

Your provider will request you complete certain laboratory tests before initiating or continuing certain medications. Laboratory tests may include, but are not limited to: saliva, hair follicle, urine, blood serum, electrocardiograms, psychological testing, genomic testing, etc.

Consent*

Laboratory testing fees are your responsibility. If your insurance plan will not cover the cost for laboratory, psychological, or other testing, you will be responsible for all costs incurred.

Billing and Insurance:

Consent*

You are responsible for understanding your insurance coverage.

Consent*

Co-pays are due at the time of check-in.

Consent*

Your insurance will be charged for services received. You are responsible for all patient balances due to co-pays, co-insurances, deductibles, tax, billing charges, late or no show charges, laboratory and psychological testing, etc.

Consent*

A charge for psychotherapy in addition to a medication management billing code may appear on your billing statement. Psychotherapy is a standard psychotherapy add-on code that all NAL medication providers use to reflect psychotherapy services that occur in session. Psychotherapy is defined in Current Procedural Terminology (CPT) by the American Medical Association as “the attempt to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development” (2012).

Genoa Pharmacy:

We have an on-site pharmacy at our New Brighton and Woodbury locations to provide you with the convenience of filling all of your medications in the privacy of our clinic. However, Genoa can also fill prescriptions for you at all other locations. Genoa can specially pre-package your medication or mail them to your residence, and they will match the pricing of other pharmacies.

Patient's Name*

First Last

Patient's Date Of Birth*

Email

Emergency Contact Printed Name

First Last

Emergency Contact Phone Number

Patient or Parent/Legal Guardian e-Signature*

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