Policies and Good Faith Estimate – Delos Psychiatry in Boulder, CO

You are entitled to receive this “Good Faith Estimate” of what the charges could be for psychiatric services provided to you. This “Good Faith Estimate” is not intended to serve as a recommendation for treatment or a prediction that you may need to attend a specified number of clinical visits. For more information, call us or schedule an appointment online. We are conveniently located at 2501 Walnut St. Suite 204 Boulder, CO 80302. We serve patients from Boulder CO, Denver CO, Silverthorne CO, Longmont CO, Superior CO, Lafayette CO, Broomfield CO, Erie CO, and Niwot CO.

Clinic Fees, Financial Policy, and Good Faith Estimate

While it is not possible to know, in advance, how many appointments may be necessary or appropriate for a given person, this form provides an estimate of the cost of services provided. Your total cost of services will depend upon the number of appointments you attend, late-cancellation/no-show fees, your individual circumstances, and the type and amount of services that are provided to you. The good faith estimate is not a contract and does not obligate you to obtain any services from the provider(s) listed, nor does it include any services rendered to you that are not identified here. All estimates are “Out of Pocket” estimates, so if you are using insurance, this does NOT include what your insurance would cover. Please call your insurance company to determine your insurance coverage.

The number of visits that are appropriate in your case, and the estimated cost for those services, depends on your needs and what you agree to in consultation with the provider. You are entitled to disagree with any recommendations made to you concerning your treatment and you may discontinue treatment at any time.

Payment is requested at time of service by cash, credit card, check, FSA or HSA card, or Venmo.

Fees are as follows:
Initial evaluation (60 Minutes; E/M): 299$
30 Min Follow Up (E/M): 175$
15 Min Follow Up (E/M): 89$
Ketamine Assisted Psychotherapy Medical Consult (30 Min): 175$
Ketamine Infusion: 349$
No Show/ Cancelation within 24 hours: Billed at 349$ per hour visit canceled, 175$ per half hour visit canceled, and 89$ per 15 min visit canceled.

All patients receive an initial evaluation unless told otherwise. After the initial evaluation, periodic follow-ups from once per week to once every 6 months will occur for 30 or 15 minutes.

Example: Initial Consultation ($299 plus 3 30-minute follow-ups (175$*3) will result in a total yearly bill of $824.

This practice is currently cash-only and not accepting insurance.

Disclaimer: This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill. If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount. To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

If your treatment is covered by your health insurance, you may request a superbill at checkout; send this form to your insurance company for reimbursement. All information needed by insurance companies for reimbursement should be included on the superbill. If your insurance company requires additional information, please let us know, so we can include it on your next superbill.

Delos Psychiatry Clinic Policies

Confidentiality:
Confidentiality is a basis of mental health treatment and is protected by the law. Aside from emergency situations, information can only be released about your care with your written permission. A release is not needed for providers of Delos Psychiatry to consult with other providers within the Practice. If insurance reimbursement is pursued, insurance companies also often require information about diagnosis, treatment, and other important information in the Disclosure of Health Information as a condition of your insurance coverage. Several exceptions to confidentiality do exist that require disclosure by law:

(1) danger to self – if there is threat to harm yourself, we are required to seek hospitalization for the client, or to contact family members or others who can help provide protection;

(2) danger to others – if there is threat of serious bodily harm to others, we are required to take protective actions, which may include notifying the potential victim, notifying the police, or seeking appropriate hospitalization;

(3) grave disability or impairment – if due to mental illness, you are unable to meet your basic needs, such as clothing, food/water, medical care, and shelter, we may have to disclose information in order to access services to provide for your basic needs;

(4) suspicion of child, elder, or dependent abuse – if there is an indication of abuse to a child, an elderly person, or a disabled person, even if it is about a party other than yourself, we must file a report with the appropriate state agency;

(5) certain judicial proceedings – if you are involved in judicial proceedings, you have the right to prevent us from providing any information about your treatment. However, in some circumstances in which your emotional condition is an important element, a judge may require testimony through a court order. Although these situations can be rare, we will make every effort to discuss the proceedings accordingly.

(6) in the event of a national emergency such as a global pandemic, terrorism, wartime, or any other catastrophic event, Delos Psychiatry will follow the Governor’s Orders of each state of the patient’s residence to ensure continuation of health care for reasonable amount of time.

* We also reserve the right to consult with other professionals when appropriate. In these circumstances, your identity will not be revealed, and only important clinical information will be discussed. Please note that such consultants are also legally bound to keep this information confidential.

Appointment Cancellation, No-Show, and Late Arrival Policy
Delos Psychiatry’s policy requires patients to cancel 1 business day in advance of their appointment to avoid paying for the appointment in full. If their appointment is on a Monday or following a long weekend, the cancellation must be made on the previous business day. Patients are expected to arrive on time for their scheduled appointments out of courtesy to the other patients and providers/clinicians. Patients who arrive more than 10 minutes late for a 30-minute appointment and 15 minutes late for a 60-minute appointment, may not be seen.

No shows (appointments not attended with no forewarning) follow a 3 strike policy. If you miss more than 3 appointments without forwarning you may be asked to leave the practice.

Discharge Policy
At the discretion of Delos Psychiatry, a patient may be discharged from the Practice if any of the following guidelines are not followed:

• Patient’s failure to follow the recommended treatment plan or medical instructions including the Controlled Substance Agreement, if applicable.
• Patient fails to meet financial responsibilities
• The provider cannot provide the level of care necessary to meet the patient’s needs.
• The member and/or member’s family is abusive to the provider and/or staff.
• The patient or provider moves out of the service area.

Controlled Substances Agreement:
Controlled substance prescriptions require an appointment every 3 months by law. If you do not attend an appointment 3 months or less after your last appointment we will not be able to continue to prescribe your controlled substances. Controlled substances may also not be refilled if provider has good reason to believe they are not being used in good faith. This includes giving or selling the medication to others and not taking the medication as prescribed.