Administrative Matters: Patient Registration Forms, Privacy Policies, Professional Practice Wills, Medicare Opt-Out Forms, Symptom Check List, Mental Health/Medical Histories, etc.

INTRODUCTION

What are the forms, policies, procedures and other administrative matter that a psychiatrist might incorporate in conducting private practice?

Psychiatrists no longer tethered to administratively dictated protocols approach this question differently.

The supportive effort, here, is to offer psychiatrists seeking to establish a private practice a sense of the variety of approaches that experienced psychiatrists tell us they incorporate in their work. This effort includes patient registration forms, privacy policies, and so forth that may be incorporated by clinicians in private practice.

Please note that certain administrative issues encountered by psychiatrists who rely on Medicare, Medicaid and insurance providers will be addressed separately.

The matters addressed follow below are 1) a disclaimer, 2) a  cross-reference list and 3) the accounts and attached policies or forms that  psychiatric clinicians use in their practice. The eight clinicians participating in this survey are assigned letters A through H.

1) DISCLAIMER

Disclaimer: The following are samples contributed by psychiatric clinicians.  They have not been reviewed or endorsed by the American Academy of Psychodynamic Psychiatry and Psychoanalysis. Nothing herein should be construed as suggesting ‘standard of care.’ These constitute opinion pieces by the contributing authors, only. Readers should locate their own experts. This site welcomes suggestions.

2) CROSS- REFERENCE LIST

>Medicare Opt-Out Affidavit Forms and Medicare Opt-Out Patient Forms (Clinician A)

>Policies on fees, insurance and billing (Clinicians A, B, H)

>Professional practice wills (Clinicians B, C),

>Privacy (Clinicians B, C, E, H),

>Treatment consent forms (Clinicians C, H),

>A reference to Wyatt’s Psychiatric Practice: Forms and Protocols for Clinical Use (Clinician D),

>The absence of all written forms or policies (Clinician E)

>The HIPAA privacy booklet that may be offered to patients (Clinician F)

>Initial patient registration forms, mental health and medical history forms (Clinicians G, H)

>Mood Checklist Form, PCL-C, Patient Health Questionnaire, GAD-7, Symptom Checklist, Beck’s Depression Inventory, Character Trait Questionnaire, Adult ADHD Self-Report Scale, ADHD Progress Diary (Clinician H)

3) CLINICIAN ACCOUNTS

Clinician A writes, “After the first phone call, I often email to new patients a statement concerning fees, billing and insurance. I let the patient know that I am non-participating with all insurance companies and ask if they would like me to email them a page that could help them find out how much reimbursement they could expect to receive from their insurance company. I would then provide them, it they like, with all the information they need to have a conversation with an insurance provider. Almost 100% of potential patients say ‘yes.’ They are extremely appreciative. This also gives them the option of not following through with me if it is too expensive for them. (See Clinician A - Fees, Billing, and Insurance).

“For patients who cannot afford my fee, I have a list of places they can contact for high-quality, low-fee treatment. People are also extremely appreciative when I let them know about this.”

Dr. A. has opted out of Medicare. He provides us with the Medicare Opt-Out Affidavit, the Medicare Private Contract, and the Medicare Private Contract in plain English for patients. He writes, “About 2017, I had a conversation with a Medicare representative (the phone number can easily be googled).  I was told that physicians no longer need to ‘opt-out’ every two years. Opting-out once is good forever. Though I rely on this advice, I cannot be certain it is correct.

“At about the same time, I was told that if the patient’s primary insurance is Medicare, and the physician submits an invoice to Medicare labelled, ‘For Denial Only,’ at the top of the claim form, the patient can then use the denied Medicare  EOB [Explanation of Benefits] to submit to his or her secondary insurer and seek reimbursement from them.  I’ve done this a couple of times, but don’t know if  it proved successful. Regardless, it is another administrative hassle.”

(See Clinician A - Medicare Opt-Out Affidavit; Clinician A - Medicare Private Contract; Clinician A - Medicare Private Contract in plain English).

Clinician A - Fees Billing and Insurance
Clinician A - Medicare Opt-Out Affidavit
Clinician A - Medicare Private Contract in Plain English

Clinician B is a psychiatrist-psychoanalyst in a cosmopolitan city. He writes, "I have been in practice for over thirty years. I never ask a new patient coming for consultation to sign forms.  Nor do tell them what my policies are—other than my privacy policy.  I say, everything we speak about in this office is confidential. I also direct them to my website for that. (See Clinician B - Privacy Policy). I don’t ask patients to sign a form that verifies I have explained my privacy policy.

“Depending on my immediate sense of the patient, even from the initial phone call, I may explain that I do not accept Medicare, that I serve on no panel, but note that I will prepare invoices to meet insurance claim requirements. I may ask for a brief description of their interest in coming to see me.  I may state my fee which I determine from considering the patient’s ability to pay as well as other factors.

“Patients are directly responsible for payment. I hand out or mail invoices at the end of the month.  Those patients who prefer to pay at the end of each session receive the monthly invoice showing, ‘Paid in Full.’ Payment is by check, or, rarely, cash. I don’t use credit cards for payment though that may change at some point.

“The treatment that I offer is psychodynamically informed and will range along a spectrum from supportive to deeply exploratory—psychoanalysis—and may include adjunctive medication. Once therapy begins, I will ask my patient that if they look for, or happen across, information about me on the internet, it would be helpful to our work for them to bring in what they have found. After a first cancelled session, for which I do not charge, I establish my cancellation policy which may range from 24 hours to 1 week. I estimate that about 30% of my therapy sessions are by telephone.

“Though I am in good health, I know life can change on a dime. About fifteen years ago, for the sake of my patients (and my own peace of mind), I established a Professional Practice Will.  I update it at 3-month intervals. The process of updating only takes minutes of my time and is well worth the effort.  If I die suddenly or become acutely incapacitated, my patients are not left uncertain about my condition or what they should do. The protocol I have devised is likely to seem complicated to others. Actually, if it is needed—as it did on one occasion—it is straightforward.  What really matters is that some plan is in place. (See Clinician B – Professional Practice Will).”

Clinician B - Privacy Policy
Clinician B - Professional Practice Will

Clinician C provides patients with a Treatment Consent Form. It describes what psychotherapy is and establishes the clinician’s policies regarding medication, availability, financial arrangements, and privacy. The form asks the patient to sign that the Consent has been reviewed and discussed and, separately, to sign that the clinician has permission to provide the minimally necessary information for purpose of payment and other health care. (See Clinician C – Treatment Consent Form; also see Clinician F – HIPAA booklet for patients).

      As with Clinician B, this clinician also keeps a Professional Practice Will. This Will was originally suggested by Stephen K. Firestein and endorsed by the American Psychoanalytic Association. (See Clinician C – Professional Practice Will)

Clinician C - Professional Practice Will
Clinician C - Treatment Consent Form

Clinician D reports that he has found Psychiatric Practice: Forms and Protocols for Clinical Use, Third Edition, (Amer. Psychiat. Pub., 2005; appi.org) to offer useful references. He has especially found the Hamilton Rating Scale for Depression (Ham-D), the Mini-Mental State Examination (MMSE), and the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) of value. He occasionally uses the drug handouts and finds other items useful as templates. The reference also contains a comprehensive initial history and intake form that this clinician describes as excellent.

      As noted in the preface to the third edition, the volume also contains “a self-assessment form for the patient to complete before the first visit, . . .[forms for] release of information, . . . a medication log. . ., handouts on major psychiatric illnesses that can be given to patients and families, . . . [and] medication handouts for patients and families.”

Clinician E is a psychiatrist-psychoanalyst in a cosmopolitan city. He takes a spare approach to offering patients written procedures and practice policies. He writes: "I've been in private practice for over 40 years.  I know others use formal documentation or ask patients to sign HIPAA agreements. I do none of that. I do not distribute written privacy policy forms, consent for treatment forms, medical history or allergy forms, permission forms to speak with other physicians, a listing of emergency numbers to call. I do nothing requiring a patient’s signature. I haven’t accepted Medicare for decades and I do not ask patients on Medicare to sign a form stating their acknowledgement that I have opted out. On emails to patients I do not include a statement asserting that the contents of my email are confidential.  On my answering machine, I ask callers to leave a message and do not say that in case of emergency, they should dial 911 or go to an emergency room.

"I elicit a patient's relevant medical history during the course of my initial evaluation and obtain more as treatment progresses and as relevant medical matters arise.  I explain my typical vacation schedule, my privacy policy and my cancellation policy when the patient and I have decided on working together in psychotherapy. As mentioned above, if I need to speak with a patient's physician, I ask for my patient's verbal permission and inform them that they need to give the other physician permission to speak with me.

"I have never had any reason to alter what I do. At no time did this uncomplicated face-to-face verbal approach to administering my practice cause difficulties for my patients or me."

Clinician F offers patients on their first visit a booklet that presents HIPAA regulations on privacy in easy language for patients (See Clinician F – HIPAA booklet for patients). He asks patients to sign a form that affirms they understand the clinician’s privacy policies. (See Clinician F – Statement of Privacy Policy) No patient, says Clinician F, has actually taken the booklet with them.

Clinician F - HIPAA booklet for patients
Clinician F - Statement of Privacy Policy

Clinician G offers a thoughtful Confidential Registration Form for patients arriving for first consultations. If she judges the patient to be in severe distress, she sees the patient immediately, deferring completion of the form. ( See Clinician G – Patient Registration Form)

Clinician G - Patient Registration Form

Clinician H sends a 30-page packet of forms for patients to complete prior to consultation. He speaks from the perspective of a psychodynamic psychopharmacologist: “Most of my patients are referred for medication evaluation and treatment by their therapists. I do have some long- term therapy patients. My work with them is much like with my work with medication patients in that I incorporate psychodynamic concepts. Concepts such as transference and unconscious process play an important role. (See Clinician H Forms – Part 1, which include the Welcome page, Office Policies, HIPAA Notice, Treatment Consent, and the Mental Health Intake Form)

“At the outset, when a patient calls my office, I ask what they are looking for—what is the nature of their problem? I want to see if addressing their needs is in my wheelhouse. I tell them up front that I don’t take insurance. The therapists who refer to me know that about my practice. But I want the caller to hear it from me. I tell them my fee. I tell them I will send them a packet of material to complete and return. Later, I will look through the returned material. l want to see what stands out. That helps me to avoid missing, say, a soft bipolar or common comorbid conditions.

“I will also review the material when the patient is with me during our initial hour-and-a-half consultation both to re-consider the person’s responses and to ensure that they can see that I take their efforts to complete the forms seriously. I thank them for completing the forms. Aside from the content of the reported material, how the form was completed can be very helpful: a scrupulous effort might suggest OCD, a pleasantly non-compliant failure to complete the forms may point to a passive-aggressive character organization, an argumentative dismissal of the form’s legitimacy may alert me to oppositionalism, and so forth. My discussion with the patient about the material in the packet can tell me a lot about characterologic issues the person faces.

“Regardless of the material contained in the form, I ask about PTSD symptoms. I’ve learned that what patients report on the forms is not necessarily reliable. PTSD is easy to overlook.

“Another value the forms offer is they establish a certain baseline of preexisting symptoms. If a patient reports, say, constipation, I can later recognize that what might seem to be an adverse effect of medication actually preceded introducing the drug.

“I like the Mood Check Form especially because it  may suggest a bipolar diagnosis. Perhaps a mood stabilizer is indicated and an antidepressant should be avoided despite a presenting complaint of depression. (Clinician H Forms – Part 2, which includes the Mood Check Form, PCL-C, Patient Health Questionnaire PHQ-9, GAD-7, Symptom Checklist, Character Trait Questionnaire, Adult ADHD Self-Report Scale, and the Attention-Deficit/Hyperactivity Disorder Progress Diary) Also, the PCL-C is a checklist for possible PTSD diagnosis.  I also use the Mini Screen 7.0.2 [copyright protected] and the Beck’s Depression Inventory [see https://www.ismanet.org/doctoryourspirit/pdfs/Beck-Depression-Inventory-BDI.pdf  ].

“I may use the PHQ-9 and ask patients to fill it out between visits if I want to get a quick sense of what is going on. I take this form, like the others, with a grain of salt. The forms are a tool and never replace the in-session evaluation I perform with my patients. Still, sometimes the PHQ-9 may show improvement and I can say, ‘Looks like your scores are coming down.’ Similarly, I may use the GAD-7. The Symptom Checklist can help to determine if physical symptoms were pre-existing or the result of medication.  The Character Trait Questionnaire is not very useful, but it may help screen for personality disorder.  The Mood Log can be helpful, if patients actually complete it regularly. Often, they don’t.  The Adult ADHD form can show progress or lack of progress for those with that diagnosis.”

Clinician H - Forms Part 1
Clinician H - Forms Part 2

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