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Eligibility for Care

I am currently licensed to provide care to adults who live in the state of Illinois, Virginia, South Dakota, Minnesota or Florida. Thus, you must be at least 18 years or older and live in Illinois, Virginia, Florida, Minnesota or South Dakota. During tele-health sessions, based on licensure laws, you would also have to be physically present in Illinois or Virginia. I welcome and provide a safe space for individuals from all backgrounds, ethnic groups, religions, races, genders, and sexual orientations. 

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Please note: I do not routinely utilize benzodiazepines or stimulants and do not routinely treat ADHD as part of my practice.

 

Billing

I am an In-Network Provider and accepting Blue Cross Blue Shield PPO insurance.  

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For all other insurance plans, I am an Out of Network Provider at this time. Patients with insurance other than Blue Cross Blue Shield PPO may use their Out-of-Network benefits to help reimburse my services. Governmental programs (i.e. Medicaid and/or Medicare) cannot not reimburse any portion of my services. I am able to provide a receipt of the service rendered and payment collected that can be submitted to your insurance company for reimbursement (i.e. a Superbill). Please contact your individual insurance company for more specific details on how to submit for reimbursement and how much would be reimbursed for "outpatient telepsychiatry" and "outpatient psychiatry" services.​​

Appointments and Cancellations

MindBodyHeart Psychiatry LLC. provides psychiatric treatment via telepsychiatry (or two-way secure video conferencing). Because of this, we do require that all patients admitted to the practice agree to and be comfortable with telepsychiatry as the primary mode of treatment. Dr. Cook is able to provide instructions on how to setup telepsychiatry visits and navigate the online platform. It is generally considered intuitive and an easy-access system. You are able to access the virtual telepsychiatry platform using a tablet, computer, or smart phone that has internet access. It is recommended that you use a private internet connection at home for the visits. Public Wi-FI security cannot be guaranteed.

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Appointments are scheduled to best meet both of our schedules and needs. Failures to keep appointments significantly impedes our treatment and could impact other patients in need as well. As such, it is our office policy to charge our full fee for a "no-show" or an appointment cancelled with less than 24 hours' notice. This also applies to any session in which you are not physically located in Illinois, Virginia or Florida at the time of your session, as these meetings will need to be rescheduled due to medical licensure laws.

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Please complete all required paperwork and consent forms at least 24 hours before your first scheduled visit. This is important for me to have an opportunity to review your documentation and be prepared for our visit. If you have not returned the required paperwork by the time of your scheduled appointment, your session may be canceled.

 

Primary Care Provider Requirement

Because of the unique nature of telemedicine and the importance of physical medicine along with psychological and social interventions, we require that you have an ongoing relationship with a local primary care provider, and that you authorize us to collaborate with that provider in your care. You will need to provide a signed release for us to communicate with your primary care provider when you submit your initial patient paperwork. You are responsible for letting our office now if you change primary care providers in the future and completing an updated release form. You may be asked to complete laboratory testing or vital sign checks through your primary care physician's office.

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Collaboration of Care

I strongly encourage that my patients are actively engaged in psychotherapy along with medication management. As such, if you are working with an outside therapist, I will encourage permission for collaboration between your therapist and me. This collaborative approach and open communication can help me to understand your individual needs and better create an individualized treatment plan for you.

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Communication

It is my intention to be available and to provide prompt email and phone support to address questions or concerns you may have in between visits. In between appointments, telephone conversations lasting longer than 10 minutes are likely to be considered phone consultations and may be subjected to our pro-rated hourly fee of $300/hr ($5 per min). Please note that if the volume of communication (i.e. phone, or electronic messaging) becomes excessive or if this privilege is misused, it could be a sign that the communication is becoming countertherapeutic. As such, I will discuss any concerning communication patterns with you directly. Depending on the need, communications requiring extensive research, time or review may be subjected to pro-rated hourly fee of $300/hr ($5/min) as well.

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My turn around time for emails and phone call is typically 24 hours. Thus, if you are in crisis, feeling suicidal, homicidal or in any other need of immediate, emergent assistance, please call 911 or go to your nearest ED

 

Letters/Additional Paperwork Requests

I am happy to complete paperwork or other letters for legal, insurance and other reasons. If filled out outside of your scheduled appointment time, letters/additional paperwork requiring greater than 5 min to complete may be subject to the pro-rated hourly fee of $300/hr ($5 per min).

 

Prescriptions and Refills

If I am providing medications as part of your treatment, I will e-prescribe all medicines to your preferred pharmacy. I require at least one appointment every 3 months to maintain anyone on a psychotropic treatment. If you do run out of medication prior to our appointment, please call or email me as soon as possible with the medicine that needs refill, and the name of the pharmacy you prefer that I send it to.

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Notice of Privacy Practices

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Privacy and Confidentiality is an important part of the treatment and practice at MindBodyHeart Psychiatry LLC. This is a notice that describes how medical information about you may is protected, may be used/disclosed and how to get access to this information. 

 

This Notice of Privacy Practices (Notice) describes the privacy practices of MindBodyHeart Psychiatry LLC. MindBodyHeart Psychiatry LLC. is required by law to protect the privacy of your health information.  This Notice is provided to comply with the federal privacy regulations known as HIPAA.  It describes how MindBodyHeart Psychiatry LLC. may use and disclose your health information.  It also describes your rights and our responsibilities about uses or disclosures of your health information.

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Our Responsibilities. We are required by law to maintain the privacy of your health information and to provide you with a notice about our legal duties and privacy practices concerning your health information. We are required to follow our Notice of Privacy Practices that is currently in effect.  We reserve the right, however, to change our Notice and to make a new Notice effective for all health information we maintain.  If we make changes to our Notice, we will notify you.  You may obtain a copy of the revised Notice by emailing cookmd@mbhpsych.com.

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Uses and Disclosures for Treatment, Payment, and Health Care Operations

Unless otherwise restricted by state law, MindBodyHeart Psychiatry LLC. may use or disclose your health information for the following purposes:

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For Treatment Purposes.  “Treatment” refers to when we provide, coordinate, or manage your health care and other services related to your health care.  An example of treatment is when we confer internally about your care with our health care providers or when we consult with another health care provider, such as your family physician or another health care professional about your care.  Those professionals, of course, are obligated to protect the privacy of your medical information just as we are.

 

For Payment Activities. “Payment Activities” refers to when we seek payment for the health care services we provide.  An example of our payment activities is when we submit claims to your insurance company or when we send out a statement for you to submit for potential reimbursement to your insurer if you so choose to do so for our out-of-network services. Like health professionals, insurance companies are also required by law to keep your records confidential. Another example is when we send our statement for services to you for payment.

 

For Health Care Operations. Our “health care operations” are activities that relate to our business. Examples of health care operations are case management and care coordination, and business planning and development activities.  Among our other business activities, we may contact you to remind you about your appointments with us. We may also contact you to give you information about treatment options or other health-related benefits and services we provide that may be of interest to you.

 

Uses and Disclosures Requiring Your Authorization

We may use or disclose your health information for purposes other than treatment, payment, or health care operations if we obtain your authorization.  An “authorization” is written document that permits the specific disclosures that are listed on the authorization form you sign.  If we need to use or disclose your health information for purposes other than treatment, payment, or health care operations, we will need to obtain an authorization from you unless the use or disclosure is otherwise required or permitted by law. 

You may revoke an authorization that you provide to us at any time if you do so in writing.  You may not revoke an authorization to the extent (1) we have taken action in reliance on the authorization; or (2) if the authorization was obtained as a condition of your obtaining insurance coverage, and the law provides the insurer the right to contest a claim under the policy.

 

Uses and Disclosures of Your Information that Do Not Require Your Consent or Authorization

In some situations, MindBodyHeart Psychiatry LLC. may use or disclose your health information without an additional consent or an authorization.  We may use or disclose your health information as required by law as long as the use or disclosure complies with and is limited by a particular law’s requirements.  For example, in situations involving

 

  • Public Health Activities. We may disclose your health information to a public health authority where it is authorized by law to collect or receive health information to prevent or control disease, injury or disability.  For example, in cases of child abuse or neglect, if we believe that a child has been subjected to abuse or neglect, or if we observe a child being subjected to conditions which would result in abuse or neglect, we must report this to the proper law enforcement or governmental agency.

 

  • Health Oversight Activities.  We may disclose your health information to a health oversight agency for activities authorized by law, including, for example, inspections and health care licensure matters.

 

  • Judicial & Administrative Proceedings.  MindBodyHeart Psychiatry LLC. may disclose your health information in responding to subpoenas, court orders, or other lawful requests related to legal proceedings in a court or before a government agency.

 

  • Law Enforcement. We may disclose your health information if asked to do so by a law enforcement official in the situations such as these:

 

  • To respond to a court order, subpoena, warrant, summons or similar types of requests from a law enforcement official.

  • In limited situations, to report abuse or domestic violence.

  • To report evidence of a crime occurring on the premises of any of our office locations.

  • In emergencies, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

 

  • Serious Threat to Health or Safety.  If you communicate to us a serious threat of physical violence against a person or a member(s) of the public, including a threat to yourself, we are permitted, consistent with applicable law and ethical standards, to communicate that threat to those who are reasonably able to prevent or lessen the threat, including law enforcement agencies.  Federal law and regulations do not protect any information about a crime committed by a patient either at one of our offices or against any person who works for us or about any threat to commit such a crime.

 

  • Emergency. If you have a medical emergency, we will share information with medical professionals to assist them in providing necessary health care to you.

  • Specialized Government Functions. We may use and disclose your health information for national security and intelligence activities authorized by law. If you are a military member, we may disclose your health information to military authorities under certain circumstances.

  • Correctional Institution and Other Law Enforcement Custodial Situations.  If you are an inmate or in the custody of law enforcement, we may share your health information with a correctional institution as necessary for your health, the health and safety of others, for law enforcement within the correctional institution, and for the institution’s administration, maintenance, safety, security, and good order.

  • Worker’s Compensation.  If you file a worker’s compensation claim, we must, on demand, make available records relevant to that claim to your employer, the pertinent insurance carrier, the worker’s compensation court, and to you.

 

Your Health Information Rights

You have the following rights regarding your health information:

  • Right to Request Restrictions.  You have the right to request limits on certain uses and disclosures of your health information as provided by law.  MindBodyHeart Psychiatry LLC. is not required to agree to a restriction you request, however, unless: (1) your request is to restrict disclosures to health plans; (2) such requested restriction limits disclosures are made for the purpose of carrying out payment or health care operations only; and (3) the requested restriction only limits disclosures relating to health care items or services for which you have paid MindBodyHeart Psychiatry LLC. out of pocket in full.

 

  • Right to Request Amendments.  You have the right to request a change to your health information if you believe the information is inaccurate or incomplete.  Under certain circumstances, however, MindBodyHeart Psychiatry LLC. may deny your request.  At your request, we will discuss with you the details of the amendment process.

 

  • Right to Receive Confidential Communications.  You have the right to ask that MindBodyHeart Psychiatry LLC. communicate with you confidentially about your health information in certain ways or at certain locations, and we will accommodate all reasonable requests to do so.  For example, you may not want a family member to know that you are being treated by us, so you may want our billing statements to be sent to a different address.

 

  • Right to Inspect and Copy.  You have the right to inspect or obtain a copy (or both) of your health information in our medical and billing records used to make decisions about you for as long as the information is maintained in the record. In some circumstances you may have the right to receive this information in an electronic format or have an electronic copy sent to an entity or individual you have clearly, specifically, and conspicuously designated. We may deny your access to your information under certain circumstances, but in some cases, you may have this decision reviewed.  At your request, we will discuss with you the details of the request and the denial review process.

  • Right to an Accounting.  You have the right to ask for an accounting (or list) of certain disclosures MindBodyHeart Psychiatry LLC. or its business associates have made of your health information.  At your request, we will discuss with you the details of the accounting process.

 

  • Right to a Paper Copy.  You have the right to receive a paper copy of this Notice upon request, even if you have agreed to receive the notice electronically. We may charge you a reasonable fee to provide you such a paper record.

 

  • Right to Receive Notification of Certain Breaches. You have the right to be notified by MindBodyHeart Psychiatry LLC. if your information is improperly used or disclosed. Generally, you will be notified about an improper use or disclosure of your information if (1) except where you opt for non-encrypted email, it was not secured by encryption or other means that follow federal standards, (2) your information was accessed, disclosed, or used in violation of federal laws, and (3) the access, disclosure, or use poses a significant risk of harm to your reputation, harm to you financially, or otherwise. This notification will contain important information about the breach and where you can obtain further information.

 

All requests to exercise these rights must be in writing. We follow established procedures to handle requests and notify you of our actions and your rights.  You may request forms or exercise your rights by contacting the Privacy Officer at cookmd@mbhpsych.com or by contacting us via contact information below.  You do not need to take any affirmative action to maintain your right to be notified about an improper use or disclosure of your information.

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Complaints

If you believe that your privacy rights have been violated or not adequately protected, please send your written complaint to MindBodyHeart Psychiatry LLC. at the following address:

 

Michelle K. Cook, MD., Privacy Officer

MindBodyHeart Psychiatry LLC.

47392 272nd St Suite 3

Harrisburgh, SD. 57032

Phone: 773-417-6213

cookmd@mbhpsych.com

You may also submit a complaint to the Secretary of the U.S. Department of Health and Human Services.  The Privacy Officer can provide you the appropriate address for the Secretary upon request.  You will not be retaliated against in any way for filing a complaint.

 

 

For More Information

If you have a question about this Notice or would like additional information about our privacy practices, please contact Privacy Officer, Dr. Michelle Cook, at the address and phone number listed above.

 

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© 2019 by MindBodyHeart Psychiatry, LLC. and © 2024 Michelle K. Murphy MD PC

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