Terms and Conditions
Last updated 03/28/23
Our Services are not intended for emergencies:
IF YOU THINK YOU HAVE AN EMERGENCY THEN CALL 911 RIGHT AWAY. If you are considering suicide or if you are thinking about taking actions that could cause harm to others or yourself, call the National Suicide Prevention Hotline anytime at 1-800-273-8255 (en Español 1-888-628-9454 ) or go to the nearest emergency room. You can also access the 24/7 Crisis Text Line by texting “HOME” to 741-741.
Peak Wellness Psychiatry, A Professional Nursing Corporation (“Peak Wellness Psychiatry”), provides operates technology services, their Websites, third party applications, and the content associated therewith, which facilitate the delivery of psychiatry services through telehealth technology to patients. The Medical Corporations, Nursing Corporations, and other licensed mental health professionals that Peak Wellness Psychiatry contracts with are solely responsible for the delivery of healthcare “Services” to patients seen through Peak Wellness Psychiatry’s online services. The Medical Groups and Nursing Corporations are third-party beneficiaries of these Terms and Conditions. “Platforms” refers to any affiliated third-party applications with Peak Wellness Psychiatry that patients may use to access the online services of Peak Wellness Psychiatry.
These “Terms and Conditions” constitute a binding agreement between Peak Wellness Psychiatry, A Professional Nursing Corporation (“Peak Wellness Psychiatry”), its “Related Parties”, “you”, “the user”. the “individual”, “patient”, “guarantor”, “patient/guarantor” (“you” and “your”) concerning your access to and use of the various services offered through the “Websites”. Peak Wellness Psychiatry, A Professional Nursing Corporation, (collectively, “Peak Wellness Psychiatry,” “we,” “us,” or “our”) owns, operates online products, and services, and contracts with third parties. These Terms and Conditions (“Terms and Conditions”) governs your access and use of our Services (as defined below) and any of our “Websites”. The term “Related Parties” referenced in this section of agreement and elsewhere in agreement, refers to “Contracted Providers of Peak Wellness Psychiatry”, “Collaborating Psychiatrists”. “Employees of Peak Wellness Psychiatry”, “Contracted Nurse Practitioners of Peak Wellness Psychiatry”, “Contracted Physicians of Peak Wellness Psychiatry”, “Contracted Physician Assistants of Peak Wellness Psychiatry”, “Contractors of Peak Wellness Psychiatry”, “contracted entities of Peak Weak Wellness Psychiatry”, and any contracted third parties of Peak Wellness Psychiatry. Related Parties are third-party beneficiaries of these Terms and Conditions. The term, “Website” or “Websites” refers to any of our company websites where we post and update these terms and conditions. The term “Services” pertains to by contracted Medical Corporations, Nursing Corporations, other licensed mental health professionals, and nurse practitioners and may include: online and technology access to telehealth services, substance use disorder diagnosis, including therapy, counseling, nutrition and health coaching, and treatment, psychiatric diagnosis and treatment, and medication prescriptions rendered by (“Providers”).
Services available on the Peak Wellness Psychiatry Websites and Platforms may be sold or offered by Peak Wellness Psychiatry or by third-party medical corporations, nursing corporations, pharmacies, labs, or other third-party partners. The Website Platform provides you with access to one or more of the Providers references on Peak Wellness Psychiatry’s Website and Platform. The Services may change from time to time, and Peak Wellness Psychiatry and/or its collaborating psychiatrist(s) may choose to add new Services or suspend or discontinue some or all of the Services, in its sole discretion. Providers may at their sole discretion choose which types of services to provide to patients based on their medical judgment; in which cause full service will have been provided. Nurse Practitioners that are contracted with Peak Wellness Psychiatry also provides nursing services on behalf of collaborating psychiatrist for patients seen in the state of California.
Use of any of the Websites or Platforms constitutes your acceptance of these Terms and Conditions. By using the Websites and/or the Platforms, you expressly agree to these Terms and Conditions. If you do not agree to all the terms and conditions of this agreement, then you may not access the Website or use any services. Any new features or tools which are added to the services shall also be subject to the Terms of Service. It is your responsibility to check this Website periodically for changes to these Terms and Conditions, including before each of your appointments. You may not use our services for any illegal or unauthorized purpose nor may you, in the use of the Service, violate any laws in your jurisdiction (including but not limited to copyright laws). The headings used in this agreement are included for convenience only and will not limit or otherwise affect these Terms. If you do not agree to all the terms and conditions of this agreement, then you may not access the Website and Platforms or use any services. It is your responsibility to check this Website and Platforms periodically for changes to these Terms and Conditions, including before each of your appointments.
These Terms and Conditions contain the following sections:
- Consent to Telehealth Services
- Your Financial Responsibility and Assignments of Benefits
- Dispute Resolution
- Intellectual Property Rights
- Notice of Privacy Practices and HIPAA
- General Terms
- Disclaimers of Warranties; Limitations of Liability; Indemnification; Release
- Requirements for Eligibility of Service
1. Consent to Telehealth Services
Peak Wellness Psychiatry and its related Providers provide mental health care services via telehealth (“Telehealth Services”). By agreeing to the terms set forth herein (this “Telehealth Consent”), you consent to the applicable (Provider”) providing services to you pursuant to these terms. The telehealth services are not a substitute for in-person health care in all cases and in certain cases you may be referred to an in-person psychiatrist as the sole discretion of the Provider. In order to use the Service, you will be required to review and agree to an informed consent regarding the use of telehealth (the “Consent To Treatment and Telemedicine/Telepsychiatry/Telehealth”).
The terms “you” and “yours” refer to the person using the Telehealth Services, or in the case of a use of the Telehealth Services This purpose of this form is to obtain your consent to participate in the applicable Peak Wellness Psychiatry and the contracted third-party Provider’s Telehealth Services.
Telehealth involves the delivery of healthcare services using electronic communications, information technology or other means between a healthcare provider (“Provider”) and a patient who are not in the same physical location. Telehealth may be used for diagnosis, treatment, follow-up and/or member education, and may include, but is not limited to:
- Electronic transmission of medical records, photo images, personal health information or other data between a member and a Provider;
- Interactions between a member and a Provider via audio, video and/or data communications; and
- Use of output data from medical devices, sound and video files.
Potential benefits of telehealth
- Can be easier and more efficient for you to access medical care and treatment.
- You can obtain psychiatry and treatment at times that are convenient for you.
- You can interact with providers without the necessity of an in-office appointment.
Privacy of telehealth
- We will not record visits with your provider unless you consent to such recording.
- If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
- If you use the Internet for telehealth, use a network that is private and secure.
- There is a very small chance that someone could use technology to hear or see your telehealth visit.
- Your provider will tell you if someone else from their office can hear or see you.
- We use telehealth technology that is designed to protect your privacy.
Potential Risks of Telehealth
- Information transmitted to your Provider(s) may not be sufficient to allow for appropriate medical decision making by the Provider(s).
- Your Provider may not able to provide medical treatment for your particular condition via telehealth and you may be required to seek alternative care.
- The inability of your Provider(s) to conduct certain tests or assess vital signs in-person may in some cases prevent the Provider(s) from providing a diagnosis or treatment or from identifying the need for emergency medical care or treatment for you.
- Given regulatory requirements in certain jurisdictions, your Provider(s) treatment options, especially pertaining to certain prescriptions may be limited.
- Delays in medical evaluation/treatment could occur due to failures of the technology and none of the foregoing can guarantee that their services will be provided without error or interruption at all times that you may wish to use those services.
- Security protocols or safeguards could fail causing a breach of privacy. While we use state-of- the-art security, no system can guard against risks of intentional intrusion or inadvertent disclosure of information.
- When using the Telehealth Services, information may be transmitted over media that are beyond the control of the Peak Wellness Psychiatry, and that may not be secure. For example, you may receive email, text, or telephone communications in connection with your use of Telehealth Services, all of which are inherently unsecured and subject to disclosure to or access by third parties (e.g., if Your phone is used by someone else, you do not keep your phone or email information up to date with the Peak Wellness Psychiatry and communications are misdirected, or the network or systems of a telecommunications provider are hacked).
By accepting this Consent to Telehealth, you acknowledge your understanding and agreement to the following:
- By using the Telehealth Services provided by Done, I agree to telehealth services. I understand that telehealth involves the delivery of health care services, including assessment, treatment, diagnosis, and education, using interactive audio, video, and data communications.
- I understand that the delivery of healthcare services via telehealth is an evolving field and that the use of telehealth in my psychiatric care and treatment may include uses of technology not specifically described in this consent.
- I understand that while the use of telehealth may provide potential benefits to me, as with any medical care service no such benefits or specific results can be guaranteed. My condition may not be cured or improved, and in some cases, may get worse.
- I agree and authorize my health care provider to release information regarding the telehealth exam to Peak Wellness Psychiatry and its affiliates.
- I have read this special Consent to Telehealth carefully, and understand the risks and benefits of the use of telehealth in the medical care and treatment provided to me through Peak Wellness Psychiatry by “Providers”.
- I give my informed consent to the use of telehealth by providers affiliated with Peak Wellness Psychiatry.
- I understand that I can withhold or withdraw this consent at any time by emailing Peak Wellness Psychiatry with such instruction. Otherwise, this consent will be considered renewed upon each new telehealth consultation with “Providers”.
- I understand expressly assume the risk of any unauthorized disclosure or intentional intrusion, or of any delay, failure, interruption, or corruption of data or other information transmitted in connection with the use of any Telehealth Services.
- I agree and authorize my health care provider to share information regarding the telehealth exam with other individuals for treatment, payment and health care operations purposes.
- I understand that the level of care provided by my provider is to be the same level of care that is available to me through an in-person medical visit. I also, understand that “Providers” may determine in his or her sole discretion that my condition is not suitable for treatment using telehealth, and that I may need to seek medical care and treatment in-person, from an in-person psychiatrist, or from an alternative source.
- I understand that the same confidentiality and privacy protections that apply to my other health care services also apply to these telehealth services.
- I understand that I have access to all of my health and wellness information pertaining to the telehealth services in accordance with applicable laws and regulations.
- I understand that I do not need to consent to telehealth services, only if I want to use telehealth services provided by Peak Wellness Psychiatry.
- I understand that in case of an emergency, I will dial 911 or go directly to the nearest hospital emergency room.
I understand and agree that I am signing this Consent electronically and that I have read this Telehealth Consent carefully, I understand the risks and benefits of the Service and the use of telehealth in the medical care and treatment provided to me by Provider(s) using the Service, and I have the legal capacity and authority to provide this consent for myself. My health care provider has previously discussed with me the information provided above. I have had an opportunity to ask questions about this information and all of my questions have been answered. I have read and agreed to a telemedicine consultation.
Not for Emergencies: Peak Wellness Psychiatry’s and Related Providers Services, Website, and Platforms are not for medical or mental health emergencies or urgent situations. You should not disregard or delay to seek medical advice based on anything that appears or does not appear on the Website or Platforms. If you believe you have an emergency, call 9-1-1 immediately. You should seek emergency help or follow up care when recommended by a Provider or when otherwise needed. You should continue to consult with your primary provider and other healthcare professionals as recommended. Always seek the advice of a physician or other qualified healthcare provider concerning questions you have regarding a medical condition and before stopping, starting, or modifying any treatment or modification.
Right to Alternative Provider:Patients seen by psychiatric nurse practitioners within Peak Wellness Psychiatry are seen on behalf of collaborating psychiatrist Marc Capobianco, MD for California patient visits only. Nurse practitioners in this practice work with a collaborating psychiatrist in states where this requirement applies. For the state of California only, you may also be referred to the collaborating psychiatrist for psychiatric services either within this practice or to their outside practice in accordance with their availability. Alternatively, you may also be referred by Peak Wellness Psychiatry or its Provider to an outside psychiatry practice or you may call your insurance company to locate a psychiatry provider. Neither Peak Wellness Psychiatry, its Providers, nor any of their collaborating psychiatrist(s) makes any guarantee of any providers’ availability to see patients nor that any appointment will occur within the desired timeframe of the patient. If you need to make alternative arrangements for seeing a different psychiatry provider, then you should promptly notify this practice same-day through email@example.com.
Consent to Receive calls, Text Messages, and Emails.
By providing your mobile number and email address, you are agreeing to be contacted by Peak Wellness Psychiatry and its Providers through phone, text messaging, and email, to receive informational, Product or Service related (e.g., progress tracking, reminders, billing appointment reminders, and invoice information, bills, etc.) messages and communications relating to the Website, App and Services. Message and data rates may apply. You are also authorizing messages to be left at the number(s) you provide within our Platforms. In the event that you provide an account guarantor then you authorize Peak Wellness Psychiatry and its Providers to communicate with your account guarantor through phone and to leave messages on their voicemail, test messages, and email about anything related to payment of services, insurance, and amounts owed. We may request to send you push notifications regarding your account or the mobile application or send you text (SMS) messages. If you wish to opt-out from receiving these types of communications, you may turn them off in your device’s settings.
2. Your Financial Responsibility and Assignments of Benefits
General terms of payment: By using our services, you are agreeing that payment for services is due to Peak Wellness Psychiatry based on the due date(s) provided on the invoice for any ‘Amounts Owed’ and must be paid through your charge card. You authorize Peak Wellness Psychiatry at its sole discretion to charge any of your charge cards on file for services rendered and for any other amounts owed as outlined in this agreement and you acknowledge that in order to make appointments at Peak Wellness Psychiatry that you must keep a valid charge card on file that accepts charges.
Patient requirement to maintain up to date information at all times: You are responsible for signing into the Website and Platforms yourself to maintain the most current billing address, mailing address, payment information, and working charge card(s) on file. In the event that your charge card is declined for any reason then you agree to promptly provide updated charge card information within our Platform to be placed on file with Peak Wellness Psychiatry upon request from Peak Wellness Psychiatry. If you provide multiple charge cards on file within our Platform then you further agree to allow any of these charge cards to be charged at the sole discretion of Peak Wellness Psychiatry. In the event that you need to change demographic and/or payment information, then you are responsible for logging into the Website and Platforms and updating this information yourself and Peak Wellness Psychiatry is not responsible for updating this information for you. You also authorize Peak Wellness Psychiatry to submit claims to your insurance(s) based on the insurance information that you provide and you assign and request that payments for insurance claims be made to Peak Wellness Psychiatry, A Professional Nursing Corporation. Any claims submitted by Peak Wellness Psychiatry is done as a courtesy and Peak Wellness Psychiatry makes no guarantee of any insurance coverage for any of our services.
Insurance.To the extent you have health insurance, and the Services are eligible for such insurance, you hereby authorize Peak Wellness Psychiatry to collect payment and charge your charge card for copayments, coinsurance, and amounts resulting from your insurance deductible plus any amounts not covered by your insurance. You hereby authorize all such charges to be charged at once in a single charge. If you provide information about your health insurance or health plan, that will be deemed your authorization for us to submit claims for our services to your health insurer or health plan. You hereby assign or otherwise authorize payment of medical benefits to us for the services provided to you. You authorize the release of any medical or other information necessary to process any claims for our services provided. You further understand and accept your financial responsibility for any portion of the bill not covered by your health insurer or health plan. SUBMISSION OF CHARGES DOES NOT WAIVE OUR RIGHT TO SEEK PAYMENT DIRECTLY FROM YOU.
Insurance Updates:You are responsible for providing the correct and most up to date primary insurance information to Peak Wellness Psychiatry within our Platforms. In the event that your primary insurance information changes then you agree to notify Peak Wellness Psychiatry same day that the change occurs through firstname.lastname@example.org. You agree to promptly follow all instructions provided to you by Peak Wellness Psychiatry within three days that you are notified by Peak Wellness Psychiatry. In the event that your primary insurance information can not be verified within 9 days of your upcoming service(s) for any reason, then you will be charged the cash pay rate(s) of these service(s). After your insurance information has been verified then you will be changed according to your insurance benefits for our services as outlined elsewhere in this agreement. Peak Wellness Psychiatry makes no guarantee of any insurance coverage for our service(s) and you may later owe additional amounts after your date(s) of service as outlined elsewhere in this agreement.
Amounts Owed:You authorize Peak Wellness Psychiatry to charge your charge card on file for the patient responsibility for all amounts owed and you understand that you are responsible for paying all amounts owed based on the due dates on the invoices that you receive and hereby authorize Peak Wellness Psychiatry to charge your charge card on file for any amounts owed within 9 days of your upcoming date of service, at the time of your date of service, and at any time after your date of service for any Amounts Owed. The `Amounts Owed’ is defined as any amount that you owe Peak Wellness Psychiatry which includes: service fees, amounts owed according to your insurance benefits (deductibles, co-insurance, copayments), services fees not covered by our insurance, services fees not covered by our insurance due to your Coordination of Benefits (COB) not being updated before, during, and after the time of service), the cash pay rates of services, No Show Fees, Cancelation Fees, Returned Check Fees, Paperwork Fees, and Administrative Fees.
The additional amounts owed may arise due to, but are not limited to claim denials, out of network insurances, service exclusions set by your insurance, inactive insurance, if you provide wrong insurance information, and/or services fees not covered by our insurance due to your Coordination of Benefits (COB) not being updated before, during, and after the time of service). In the event that a claim is denied then you agree that your charge card will be charged the cash pay rate of services. In the event that your charge card(s) are declined then you agree to promptly update your payment information with a working charge card and consent to have your charge cards re-charged indefinitely until the charge is successful or you place a new working charge card(s) on file and the charge is successful. In the event that any unpaid balance(s) continue to go unpaid then Peak Wellness Psychiatry may, without notice and at our sole discretion, send these unpaid balances and your account(s) to collection agencies.
Insurance Benefits not a Guarantee of Insurance Payment:You further understand that benefits and eligibility information received from your insurance is not a guarantee of payment and eligibility and Peak Wellness Psychiatry does not make any guarantee of any sort that your insurance company will cover services nor is Peak Wellness Psychiatry responsible for any financial loss(es) that may incur on your part as a result of any amount(s) owed. Any list of in-network insurances listed on the Website and Platforms of Peak Wellness Psychiatry is not a guarantee of payment and eligibility and Peak Wellness Psychiatry does not make any implied nor guarantee of any sort that your insurance company will cover services nor is Peak Wellness Psychiatry responsible for any financial loss(es) that may incur on your part as a result of any amount(s) owed. The entirety of this written agreement supersedes any information provided by Peak Wellness Psychiatry to you outside of this agreement anything including verbally and/or in writing.
In Network Insurance:In event that your insurance is in-network and accepts coverage then the `Amounts Owed” provision of this agreement will still apply in its entirety and you will be responsible for paying for the services according to your insurance benefits. In the event that your insurance is in network and does not cover services then you will be responsible for paying the cash pay rate for any services not covered by your insurance plan. The cash pay cost of service is $289 for an initial evaluation and $159 for follow-up appointment and is subject to change at any time which will be updated in the agreement and placed on the Website. In the event that eligibility information obtain from your insurance states that $0 is owed then you will be charged $1 and refunded $1 in order to verify that your payment method that you provided on file within our Platforms is working correctly, which may be charged up to 9 days in advance of your appointments in accordance with the `Amounts Owed’ provision. It is your responsibility to check the Website and Platforms periodically for changes and before each of your appointments for changes in the cash pay rate and changes to this agreement.
Amount Charged: The amount charged to your charge card on file will be based on the estimated level of service and your insurance benefits such as deductible, co-insurance, copayment, and whether your insurance covers telehealth services from Peak Wellness Psychiatry. In certain cases the actual level of service may be less than estimated level of service. If this is the case then you will receive a credit after the visit according to your insurance benefits. In other cases, the level of service may be more than estimated level of service. If this is the case then you will be charged any additional amount owed in accordance with your insurance benefits. After your visits, you will receive an invoice with the payment amounts. If you do not receive an invoice then you may contact Peak Wellness Psychiatry directly through email@example.com.
You are Responsible for Knowing Your insurance Benefits: You are solely responsible for knowing your own insurance benefits and coverage at all times and Peak Wellness Psychiatry is not responsible for knowing your insurance benefits and insurance coverage. It is your ultimate responsibility to check and understand your benefits including, but not limited to, whether your insurance required a prior authorization before seeking services, a referral from your primary care provider allowable costs for psychiatric services, the types of services covered, service exclusions, and how many visits are allowed by your insurance. You are personally responsible for all allowable fees as directed by your insurance company, as well as non-covered services that your insurance may not pay for. These fees may include, but are not limited to: copay, a co-Insurance, and a deductible. Certain insurance plans will authorize a specific number of visits for a certain period of time. You will be personally liable for any visits that fall outside of that scope and are denied by your plan. Ultimately it is your responsibility to know your policy coverage and any service exclusions. Any benefits and eligibility information received from your insurance is not a guarantee of coverage. Any in-network insurance listed on Websites and Platforms of Peak Wellness Psychiatry is not a guarantee of coverage as health insurance coverage is decided by your insurance company.
Out of Network insurance and Cash Pay Rates:If your insurance is out-of-network with Wellness Psychiatry, then you will be charged $289 for an initial consultation and $159 for follow-up appointments and the `Amount Owed’ provision of this agreement will still apply in its entirety. You are responsible for knowing your insurance benefits. You are consenting to receive and pay for services if Peak Wellness Psychiatry is out of network with your insurance plan. In the event that you wish to submit your bill to your insurance company then you can request from Peak Wellness Psychiatry a superbill, which you can submit to your insurance company for reimbursement. However, Peak Wellness Psychiatry makes no guarantee of any payment of services by your insurance. The cash pay rates are subject to change at any time which will be updated in the agreement and placed on the Website. It is your responsibility to check the Website and Platforms periodically for changes and before each of your appointments for changes in the cash pay rate and changes to this agreement.
In the event that your insurance company reimburses you for the services performed by Peak Wellness Psychiatry and you do not provide the full insurance payment(s) directly to Peak Wellness Psychiatry then you will be charged by Peak Wellness Psychiatry, without prior notice, for any payment amount(s) that you received from your insurance company. In the event that Peak Wellness receives and processes insurance payments from your out of network insurance company that is less than our established cash pay rates, then you will only be for refunded these payment amount(s).
Insurance Information Received After Date of Service: In the event that you provide Peak Wellness Psychiatry with new updated insurance information after your visit has occurred and you would like Peak Wellness Psychiatry to submit an insurance claim to this insurance, then you must notify Peak Wellness Psychiatry in writing at firstname.lastname@example.org with the dates of services, insurance name, group number, and copy of the front and back of your insurance card. In the event that additional information is needed from you by Peak Wellness Psychiatry then you agree to provide this information electronically by whatever method is requested by Peak Wellness Psychiatry and you agree to provide any requested information from Peak Wellness Psychiatry within three days. In the event that the claim(s) are denied for any reason then you will be still be responsible for paying the cash pay rates of the visits that were posted on the Website and Platforms of Peak Wellness Psychiatry and in effect at the time services rendered. In the event that these claim(s) are accepted then you will be charged in accordance with the `Amount Owed’ as outlined elsewhere in this agreement.
Secondary Insurance:Peak Wellness Psychiatry does not bill secondary insurance. If you wish to bill your secondary insurance then you must request a superbill, which you can submit to your secondary insurance for reimbursement. If your secondary insurance does not pay your claims then it will be your responsibility to contact this carrier to resolve any issues of coordination with coverage. Peak Wellness Psychiatry makes no guarantee of insurance coverage and is not responsible for any claim denials. In the event that your insurance company reimburses you for the services performed by Peak Wellness Psychiatry and you do not provide the full insurance payment(s) directly to Peak Wellness Psychiatry then you will be charged by Peak Wellness Psychiatry, without prior notice, for any payment amount(s) that you received from your insurance company.
Coordination of Benefits: You are responsible for ensuring that your Coordination of Benefits (COB) is updated correctly at all times with your insurances, otherwise your insurance will either deny payment and/or coverage or later revoke payment and/or coverage when this is not updated correctly. As a result, you agree to promptly follow all instructions provided to you by Peak Wellness Psychiatry within three days that you are notified by Peak Wellness Psychiatry. In the event that your COB is not updated within 9 days of your upcoming service(s), then you will be charged the cash pay rate(s) of these service(s). After you update your COB then your eligibility information will be re-verified by Peak Wellness Psychiatry with your insurance. Only after your insurance provides written evidence that your COB has been updated will you be able to be charged according to insurance benefits. Peak Wellness Psychiatry will make the sole determination that proof of COB update had occurred. In the event that your insurance later denies the claim for any reason or Peak Wellness Psychiatry later determines that your COB has not been updated then you will later be charged the cash pay rate(s) for these services.
Peak Wellness Psychiatry is unable to update your COB for you due to insurance requirements that the main policy holder update their COB since your COB tells your insurance which insurance is your primary insurance that is accepting responsibility for claims. In the event that you have a secondary insurance then Peak Wellness Psychiatry will only bill the primary insurance, however you can request a superbill from Peak Wellness Psychiatry for you to submit to the secondary insurance.
Missed Appointment and Cancelation/Reschedule Policy: If you need to cancel your appointment, then you are responsible for emailing email@example.com using the same email address that is registered in our system and providing your full legal name, date of birth, and the appointment date(s) and time(s) that you wish to cancel.
You authorize Peak Wellness Psychiatry to charge your charge card a nonrefundable $100 Cancellation Fee for appointments canceled or rescheduled for any reason between 24 to 48 hours prior to any of your scheduled appointment times. In the event that you provide a cancellation notice or request to reschedule your appointment for any reason within 24 hours of your appointment(s), or after your scheduled appointment date and time has started, then you authorize Peak Wellness Psychiatry to charge your card a nonrefundable No Show and Cancellation Fee of $289 for initial appointments and $159 for follow-up appointments, based on the cash pay rate of appointments. In the event that you do not attend your scheduled appointment then you authorize Peak Wellness Psychiatry to charge your card a nonrefundable No Show and Cancellation Fee of $289 for initial appointments and $159 for follow-up appointments, based on the cash pay rate of appointments. Peak Wellness Psychiatry may at its sole discretion, apply any previous payments made for the missed appointment towards the no show fee which will be considered nonrefundable. All time frames for missed appointments are based on the time zone of the respective service location of the practice location for which the appointment(s) were made.
The appointment date and time(s) that are in our Platforms will be considered proof that you mutually agreed on the respective date, time, and specific service(s). In the event that a dispute arises that you did not agree to this appointment then you agree that the appointment scheduled within our Platform will be considered proof that you mutually agreed with Peak Wellness Psychiatry to this scheduled appointment time(s).
If for any reason, you enter the appointment session more than 20 minutes late for an initial appointment and 10 minutes late to a follow-up appointment in which you are not signed into the telehealth software then you further understand that this will be counted as a missed appointment, that you will not be evaluated, and that you will need to re-schedule and subject to the No Show and Cancellation Fee of $289 for the initial appointment and $159 for follow-up appointments.
In the event that a dispute arises between you and Peak Wellness Psychiatry on your arrival time or missed appointments, then you agree that the session record (with the patient name and the date and time that patient entered session) and a copy of the appointment record (that states appointment was missed) will be used as the sole determinant to establish that you missed your appointment or that your appointment was a no show.
Peak Wellness Psychiatry may at its sole discretion apply any credits that you have in your account from previous payments toward unpaid amounts owed for other fees including, but not limited to, No Show Fees, Cancelation Fees, and services fees.
You also accept responsibility to follow the setup instructions for telehealth and that your equipment (e.g. webcam) is tested and correctly working prior to your scheduled visits and understand that Peak Wellness Psychiatry is not responsible for ensuring that your equipment is working properly for visits (e.g. your computer, webcam, internet connection).
Patient out of state at time of appointment: In the event that you are going to be out of the state for the respective appointment, then you understand that you can not be seen for your appointment(s) and you are still required to follow the same cancelation guidelines. Out of state is defined as being in another state other than the service location state that your appointment is scheduled for. If you provide between 24 to 48 hours notice before your appointment(s) that you will be out of state for any reason then you will be charged a $100 cancelation fee. If you provide less than 24 hours notice before your appointment(s), or after your scheduled appointment date and time has started, that you will be out of state for any reason then you will be charged a nonrefundable No Show and Cancellation Fee of $289 for initial appointments and $159 for follow-up appointments, based on the cash pay rate of appointments. At its sole discretion, Peak Wellness Psychiatry reserves the right to change or modify the Missed Appointment Policy at any time and it is your responsibility to check the Website and Platforms periodically for changes and before each of your appointments for changes in the cash pay rate and changes to this agreement.
No Refund Policy: You agree to a `No Refund Policy’ for the Amount Owed as outlined elsewhere in this agreement for services provided by Peak Wellness Psychiatry for any reason. You agree that services will have been considered to have been provided in full by Peak Wellness Psychiatry (in accordance with service descriptions listed on Websites and Platforms) in the event that you enter the appointment session regardless of session length or in the event that you are dissatisfied with the services. In the event that a payment dispute arises between you and Peak Wellness Psychiatry that services were not provided in full for any patient visit(s) or you are dissatisfied with any service(s) for any reason, then you agree that the session record with the patient name and the date and time that patient entered session will be used as the sole determinant to establish that full service was provided. The estimated appointment times provided in the service description posted on the Website and Platforms are estimates only and not a guarantee of any specific appointment duration. Peak Wellness Psychiatry makes no implied nor expressed guarantee of any particular patient treatment plan nor prescribing any particular medication to the patient as a condition of full service being provided. The entirety of this written agreement supersedes any information provided by Peak Wellness Psychiatry to you outside of this agreement anything including verbally and/or in writing.
Paperwork and administrative fees:Any letters or other administrative paperwork you request are subject to a fee of $50 for every 15 minutes of time spent outside of the visit filling out paperwork. All paperwork is based on medical necessity and at the discretion of the provider. The cost for your Peak Wellness to release your personal medical records is at least $30 for each time that medical records are released, which must be paid before medical records are released. Peak Wellness Psychiatry reserves the right to charge for additional administrative services including, but not limited to, prior authorizations, and time spent calling your insurance. Any fees or charges incurred will be due upon receipt of invoice and are non-refundable in accordance with the “No Refund Policy” section”.
Coordination of Care: Peak Wellness Psychiatry may at its sole discretion charge for time spent speaking to other Providers or coordination of care outside of your appointment time, which will be billed at a rate of $50 for every 15 minutes. Any fees or charges incurred will be due upon receipt of invoice and are non-refundable in accordance with the “No Refund Policy” section”.
Disputes: In the event of any payment dispute, you agree to contact firstname.lastname@example.org in writing before taking any further action or requesting any additional services.
3. Dispute Resolution
Peak Wellness Psychiatry will try to work in good faith to resolve any issue you may have with our Services if you bring that issue to the attention of our customer service department. However, we realize that there could be rare cases in which we are unable to resolve the issue to the customer’s satisfaction. In the event that you have a dispute with us, you agree to resolve such a dispute on an individual basis in accordance with the provisions outlined below.
Initial Dispute Resolution: In the event of any concerns. our customer support department is available to address concerns or questions you may have regarding Services. The parties to use their best efforts through the support process to settle any dispute, question, or disagreement and engage in good faith negotiations which shall be a condition to either party initiating arbitration. Any failure to engage in this process could result in the award of fees against you in arbitration. To adequately engage in initial dispute resolution, you must send an email to email@example.com with your concern or question.
Arbitration:The term“Related Parties”referenced in this section of agreement and elsewhere in agreement, refers to “Contracted Providers of Peak Wellness Psychiatry”, “Collaborating Psychiatrists”. “Employees of Peak Wellness Psychiatry”, “Contracted Nurse Practitioners of Peak Wellness Psychiatry”, “Contracted Physicians of Peak Wellness Psychiatry”, “Contracted Physician Assistants of Peak Wellness Psychiatry”, “Contractors of Peak Wellness Psychiatry”, “contracted entities of Peak Weak Wellness Psychiatry”, and any contracted third parties of Peak Wellness Psychiatry. You, Peak Wellness Psychiatry, employees of Peak Wellness Psychiatry, Contractors of Peak Wellness Psychiatry, Related Parties, and any of Peak Wellness Psychiatry’s Contractors mutually agree to our respective rights to resolutions of disputes in a court of law by a judge and agree to resolve any claims or dispute against each other on an individual basis in arbitration. This will prohibit you from bringing any class, collective, or consolidated action against Peak Wellness Psychiatry and any of its Related Parties, and will also prohibit you from participating in or recovering relief under any current or future such actions brought against Peak Wellness Psychiatry, its Related Parties, by someone else.
You, Peak Wellness Psychiatry, and its Related Parties, agree that any dispute, claim, or controversy, whether based on past, present or future events, arising out of or relating to: this Agreement and prior versions thereof (including the breach, termination, enforcement, interpretation or validity thereof); the Website and/or App; any content currently or previously available on or through the Website and/or App; any Products or Services; your relationship with Peak Wellness Psychiatry and its Related Parties; your user data; the threatened or actual suspension, deactivation, or termination of your Account or this Agreement; payments made by you or any payments made or allegedly owed to you; any promotions, benefits, or other offers; and any other federal and state statutory and common law claims (collectively, “Disputes”) will be settled by binding arbitration, except that each party retains the right to bring an individual action in small claims court and the right to seek injunctive or other equitable relief in a court of competent jurisdiction (which shall be exclusively in the state or federal courts located in CA) to prevent the actual or threatened infringement, misappropriation or violation of a party’s data or copyrights, trademarks, trade secrets, patents or other intellectual property rights. All disputes concerning the arbitrability of a Dispute (including disputes about the scope, applicability, enforceability, legality, revocability, or validity of the Arbitration Agreement) will be decided by the arbitrator, except as expressly provided herein. You acknowledge and agree that you and Peak Wellness Psychiatry are each waiving the right to a trial by jury or to participate as a plaintiff or class in any purported class, collective, or consolidated proceeding. Further, unless you and Peak Wellness Psychiatry otherwise agree in writing, the arbitrator may not consolidate more than one person’s claims, and may not otherwise preside over any form of any class, collective, consolidated or representative proceeding.
The arbitration will be administered by the American Arbitration Association (“AAA”) in accordance with the Consumer Arbitration Rules (the “AAA Rules”) then in effect, except as modified by this Agreement. The Federal Arbitration Act (“FAA”) will govern the interpretation and enforcement of this Arbitration Agreement. It is your, Peak Wellness Psychiatry, and its Related Parties intent that the FAA and AAA Rules will preempt all state laws to the fullest extent permitted by law. If the FAA and AAA Rules are found to not apply to any issue that arises under this Arbitration Agreement or the enforcement thereof, then that issue will be resolved under the laws of the State of California. This Agreement governs to the extent it conflicts with the AAA Rules or FAA.
Article 1: Agreement to Arbitrate:It is understood that any dispute as to medical and/or nursing malpractice, that is as to whether any medical and/or nursing services rendered under contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated:It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the nurse practitioner, or provider including any spouse or heirs of the patient and any children, whether born or unborn, at the time of occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient herein shall mean both the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against Peak Wellness Psychiatry, its Parties, the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by Peak Wellness Psychiatry or its Parties to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law:A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator within thirty days and a third neutral arbitrator shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party by such party’s acting in the capacity of arbitrator under this contract. The immunity shall supplement, not supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and join in the arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and join any existing court action against such additional person or entity shall be stayed pending arbitration.
Article 4: Revocation:It is the intent of this agreement to apply to all medical services rendered any time for any condition. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
Notice:You are agreeing to have any dispute arising out of the matters included in this arbitration agreement decided by neutral arbitration as provided by California law and you are giving up any rights you might possess to have the dispute litigated in a court or jury trial and you are giving up your rights to discovery and appeal, unless those rights are specifically included in this arbitration agreement section. If you refuse to submit to arbitration after agreeing to this provision, you will be compelled to arbitrate, where applicable by law, under the authority of California Code of Civil Procedure.
CLASS ACTION WAIVER: YOU, PEAK WELLNESS PSYCHIATRY AND ITS RELATED PARTIES, AND THE ARBITRAL PARTIES MUTUALLY AGREE TO WAIVE OUR RESPECTIVE RIGHTS TO RESOLUTION OF DISPUTES IN A COURT OF LAW BY A JUDGE OR JURY AND AGREE TO RESOLVE ANY CLAIM OR DISPUTE AGAINST EACH OTHER ON AN INDIVIDUAL BASIS IN ARBITRATION.This will prohibit you from bringing any class, collective, or consolidated action against Peak Wellness Psychiatry and its Related Parties or any of the Arbitral Parties, and will also prohibit you from participating in or recovering relief under any current or future such actions brought against Peak Wellness Psychiatry and its Related Parties or any of the Arbitral Parties by someone else.
4. Intellectual Property Rights
Exception – Litigation of Intellectual Property and Small Claims Court Claims.
Notwithstanding the parties’ decision to resolve all disputes through arbitration, either party may bring an action in state or federal court to protect its intellectual property rights (“intellectual property rights” means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights). Either party may also elect to have disputes or claims resolved in a small claims court that are within the scope of that court’s jurisdiction. Either party may also seek a declaratory judgment or other equitable relief in a court of competent jurisdiction regarding whether a party’s claims are time-barred or may be brought in small claims court in your state and county of residence. Seeking such relief shall not waive a party’s right to arbitration under this agreement.
Property Intellectual Rights and Content:Peak Wellness Psychiatry is the sole and exclusive owner of the Websites and Platforms, including any and all copyright, patent, trademark, trade secret and other ownership and intellectual property rights, in and to the Websites and Platforms and any related materials and documentation. No title or ownership of the Websites and Platforms or any portion thereof is transferred to you hereunder. Peak Wellness Psychiatry reserves all rights not expressly granted hereunder. You agree not to change or delete any copyright or proprietary notice related to materials downloaded from the Websites and/or Platforms.
Feedback that you provide us:You may provide input, comments or suggestions regarding the Websites and Platforms or services. You acknowledge and agree that Peak Wellness Psychiatry may use any Feedback without any obligation to you and you hereby grant Peak Wellness Psychiatry a worldwide, perpetual, irrevocable, royalty-free, transferable license to reproduce, display, perform, distribute, publish, modify, edit or otherwise use such Feedback as Peak Wellness Psychiatry may deem appropriate, without restriction, for any and all commercial and/or non-commercial purposes, in its sole discretion. We are and shall be under no obligation (1) to pay compensation for any comments; (2) to maintain any comments in confidence; or (3) to respond to any comments. You further agree that your comments will not contain libelous or otherwise unlawful, abusive or obscene material, or contain any computer virus or other malware that could in any way affect the operation of the Service or any related website. You may not use a false e-mail address, pretend to be someone other than yourself, or otherwise mislead us or third-parties as to the origin of any comments.
5. Notice of Privacy Practices and HIPAA
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Medical Information:The term “medical information” is synonymous with the terms “personal health information” and “protected health information” for purposes of this Notice. It essentially means any individually identifiable health information (either directly or indirectly identifiable), whether oral or recorded in any form or medium, that is created or received by a health care provider, health plan, or others and 2) relates to the past, present, or future physical or mental health or condition of an individual (you); the provision of health care (e.g., mental health) to an individual (you); or the past, present, or future payment for the provision of health care to an individual (you). In general, patient records, and information about patients, are treated as confidential and are released to no one without the written authorization of the patient, except as indicated in this notice or except as may be otherwise permitted by law.
Uses and Disclosures Without Your Authorization – For Treatment, Payment, or Health
Care Operations: Federal privacy rules (regulations) allow health care providers who have a direct treatment relationship with the patient (you) to use or disclose the patient’s personal health information, without the patient’s written authorization, to carry out the health care provider’s own treatment, payment, or health care operations.
An example of a use or disclosure for treatment purposes: If your Provider decides to consult with another licensed health care provider about your condition, your Provider would be permitted to use and disclose your personal health information, which is otherwise confidential, in order to assist me in the diagnosis or treatment of your mental health condition.
Disclosures for treatment purposes are not limited to the minimum necessary standard. because physicians and other health care providers need access to the full record and/or full and complete information in order to provide quality care. The word “treatment” includes, among other things, the coordination and management of health care among health care providers or by a health care provider with a third party, consultations between health care providers, and referrals of a patient for health care from one health care provider to another.
An example of a use or disclosure for payment purposes: If your health plan requests a copy of your health records, or a portion thereof, in order to determine whether or not payment is warranted under the terms of your policy or contract, your Provider is permitted to use and disclose your personal health information.
An example of a use or disclosure for health care operations purposes: If your health plan decides to audit a Provider or Peak Wellness Psychiatry in order to review the accuracy of a claim, your mental health records may be used or disclosed for those purposes.
PLEASE NOTE: Your Provider or Peak Wellness Psychiatry may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Your prior written authorization is not required for such contact.
Other Uses and Disclosures Without Your Authorization:
Peak Wellness Psychiatry and/or your Provider may be required or permitted to disclose your personal health information (e.g., your mental health records) without your written authorization. The following circumstances are examples of when such disclosures may or will be made. You may also complain to the Secretary of the U.S. Department of Health and Human Services with additional inquiries if you have additional concerns about your privacy rights. While we strive to protect your personal information, we cannot ensure the security of the information you transmit to us, and so we urge you to take every precaution to protect your personal data. No data transmission over the Internet or through mobile devices can be guaranteed to be 100% secure. There is no guarantee that information may not be accessed, disclosed, altered, or destroyed by breach of any of our physical, technical, or managerial safeguards. It is your responsibility to protect the security of your login information. Change your passwords often and use a combination of letters and numbers.
Possible reasons for health information may include, but are not limited to:
- If disclosure is compelled by a court pursuant to an order of that court
- If disclosure is compelled by a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful
- If disclosure is compelled by a party to a proceeding before a court or administrative agency pursuant to a subpoena, subpoena
duces tecum (e.g., a subpoena for mental health records), notice to appear, or any provision authorizing discovery in a proceeding before a court or administrative agency.
- If disclosure is compelled by a board, commission, or administrative agency pursuant to an investigative subpoena issued pursuant
to its lawful authority.
- If disclosure is compelled by an arbitrator or arbitration panel, when arbitration is lawfully requested by either party, pursuant
to a subpoena duces tecum (e.g., a subpoena for mental health records), or any other provision authorizing discovery in a proceeding before an arbitrator or arbitration panel.
- If disclosure is compelled by a search warrant lawfully issued to a governmental law enforcement agency.
- If disclosure is compelled by the patient or the patient’s representative pursuant to Chapter 1 (commencing with Section 123100) of
Part 1 of Division 106 of the California Health and Safety Code, by corresponding federal statutes or regulations (e.g., the federal “Privacy Rule,” which requires this Notice),
or by Health and Safety code of another state.
- If disclosure is compelled or by the California Child Abuse and Neglect Reporting Act (for example, if I have a reasonable
suspicion of child abuse or neglect).
- If disclosure is compelled by a state Elder/Dependent Adult Abuse Reporting Law (for example, if your Provider has a reasonable suspicion of elder abuse or dependent adult abuse).
- If disclosure is compelled or permitted by the fact that you are in such mental or emotional condition as to be dangerous to yourself or to the person or property of others, and if I determine that disclosure is necessary to prevent the threatened danger.
- If disclosure is compelled or permitted by the fact that you tell me of a serious threat (imminent) of physical violence to be committed by you against a reasonably identifiable victim or victims.
- If disclosure is compelled or permitted, in the event of your death, to the coroner in order to determine the cause of your death.
- As indicated above, your Provider permitted to contact you without your prior authorization to provide appointment reminders or information about alternatives or other health-related benefits and services that may be of interest to you. Be sure to let your Provider know where and by what means (e.g., telephone, letter, email, fax) you may be contacted.
- If disclosure is required or permitted to a health oversight agency for oversight activities authorized by law, including but limited to, audits, criminal or civil investigations, or licensure or disciplinary actions. The respective Board of Nursing, who licenses nurse practitioners, is an example of a health oversight agency.
- If disclosure is compelled by the U. S. Secretary of Health and Human Services to investigate or determine my compliance with privacy requirements under the federal regulations (the “Privacy Rule”).
- If disclosure is otherwise specifically required by law.
Please Note: The above list is not an exhaustive list, but informs you of most circumstances when disclosures without your written authorization may be made. Other uses and disclosures will generally (but not always) be made only with your written authorization, even though federal privacy regulations or state law may allow additional uses or disclosures without your written authorization.