Carla Velarde, MD MPH
10 Office Park Way, Ste 100
Pittsford, NY 14534

POLICIES & PROCEDURES

Please take the time to carefully read this document in its entirety as it sets forth the office policies of Carla Velarde, MD MPH and contains many elements important to your care. Please ask if you have any questions. I take your care very seriously and want to make sure you agree to my policies before you are seen for an initial consultation.

Initial Consultation

During the initial consultation, I aim to provide thoughtful treatment recommendations by meeting one to three times for an initial assessment. These sessions allow us to assess our compatibility and "fit". I encourage you to be as candid as possible regarding any concerns you may have over the course of these initial meetings. At the end of the initial consultation(s), you will be provided with a working diagnosis and treatment recommendations which might include services that I am unable to provide (such as requiring a higher level of care based on the current acuity level). Completing the evaluation process does not mean that I have assumed responsibility for your care; this decision will be based on the treatment recommendations provided. If I have determined that I will be unable to enter a treatment relationship, I will provide you a list of more suitable providers.

Treatment Process & Termination

I expect our work to be helpful to you, but no psychiatrist can ethically guarantee success. I encourage you to ask questions about your progress during your treatment. I have a responsibility to evaluate your progress. Please be frank and open about your assessment of your progress throughout treatment.

You have the right to choose any psychiatrist for yourself. If, at any time, you feel there is some incompatibility between us, please mention the problem to see if it can be resolved. I will give you names of other qualified psychiatrists upon request. You have the right to end treatment or consultation at any time. Termination generally occurs when we mutually agree that goals have been reached or there is some other reason to terminate. I recommend that you discuss this important issue with me before you leave. Under ordinary circumstances, it is advisable to plan your final session with me in advance.

I will not begin care, or will not continue care, if in my professional opinion I can no longer be of benefit to you or if in my professional opinion you require a higher level of care. In such cases, I will provide you with referrals for continued treatment and discharge you if appropriate. Discharge may also occur if I am unable to communicate with you or schedule an appointment for three months.

Appointments

Patients are seen by appointment only. They are expected to start and end on time. Patients are scheduled for appointments at least once every three months, unless there are exceptional circumstances. Appointments are typically conducted in person, but telehealth appointments can be arranged on a case-by-case basis. For telehealth appointments, patients must be located in New York State.

In case of emergencies, same-day appointments may be accommodated when possible. To schedule an appointment, please contact the office at 585-902-0226 or send a message through the Charm Health patient portal.

Cancellations

A $100 fee will be applied for missed appointments or those not cancelled at least 24 hours in advance. You are responsible for paying all missed appointment fees personally, as insurance companies do not cover such charges.

Payment

Full payment for services (including insurance copayment and deductible) is required at the time of your appointment. Unless paying by check, a credit or debit card on file is required. You can use the Charm Health patient portal to upload and update cards.

If you are using Excellus BCBS benefits and have specific billing issues or concerns, they can be addressed directly by calling my billing office at 585-594-4574. I am an out-of-network provider with all other insurance companies and full payment is due at the time of session. Upon request, I can provide you a claim statement (also known as a "Super Bill") which can be submitted to your insurance company for possible partial reimbursement. However, I am unable to assist with difficulties in obtaining reimbursement from insurance carriers with whom I am not an in-network provider.

Please be aware that your insurer may not cover all services provided, and you are ultimately responsible for payment of all services rendered. Any outstanding balance remaining for more than 90 days may be referred to a collections agency.

Prescriptions and Refills

Before prescribing any controlled substances, such as stimulant medications, I review the New York State controlled substance database. Prescriptions are typically sent following appointments and are intended to cover the period until the next appointment. If additional refills are needed, they can be requested through the Charm Health patient portal, by calling/texting my office at 585-902-0226, or by requesting refills through the pharmacy. Please do not email refill requests, as they can be easily missed in my inbox.

You may be required to schedule a follow-up appointment before refills are prescribed. I reserve the right to decline issuing prescription refills if medications have been lost or stolen, or if you have missed an appointment. I will not refill stimulant medications or other controlled substances early under any circumstances. Please allow 2-3 business days for all refill requests, although I will make every effort to fill them as soon as possible.

If you encounter any difficulty obtaining your medication from the pharmacy, you agree to contact the pharmacy and speak to a pharmacy representative before contacting me. Most issues related to medications are insurance or pharmacy-related and can be resolved by directly contacting the pharmacy.

After-Hours, Holiday, and Emergency Coverage

My regular office hours are 8AM-5PM on Tuesday-Friday. For non-urgent issues (such as prescription refills, appointment requests, and other matters not requiring an immediate response) please call my office at 585-902-0226 or send a message through the Charm Health patient portal. Non-urgent messages will be answered as soon as possible, but please allow up to 2-3 business days. For questions that require clinical decision making, you will likely be asked to make an appointment so that your concerns can be fully addressed.

For urgent issues, please call my office at 585-902-0226; do not text, email or use the Charm Health patient portal for urgent issues. If you are calling with an urgent issue during business hours, please allow one to two hours for a response as I am typically with patients. For severe emergencies where you cannot wait for my call back, you agree to call 911, the Suicide & Crisis Lifeline at 988, the Monroe County Mobile Crisis Team at 585-529-3721 or go directly to the nearest emergency department.

For urgent issues after business hours, on a weekend, or holiday, please call my office and leave a voicemail indicating your urgent concern. I will return your call as soon as possible, specifically within 2 hours if it is during the day. If an urgent issue arises between 8pm and 8am, you understand that I will respond by the next morning. If I am on vacation, there will be another physician "on-call" and available to you. However, if you are suicidal, fear that you will harm yourself or others, suspect you are having a severe allergic reaction to a medication, face a life-threatening emergency, or cannot wait overnight for a call back for any other reason, you agree to call 911, 988 or go to the nearest emergency room. Instruct the emergency room to notify me at 585-902-0226.

Confidentiality

You have the right to confidentiality regarding everything discussed in our appointments. While I reserve the right to consult with professional colleagues about your case, I do so in a manner that protects your anonymity. Under the HIPAA Privacy Rule, I may share your health information with your other treatment providers (such as your primary care provider or therapist) for treatment purposes without requiring your authorization. However, I always strive to communicate my intention to reach out to these providers before doing so. The only way I will share information about you with anyone else (such as school personnel or extended family members) is if you first sign a "Release of Information" form which specifies who is to receive the information and what is to be shared.

The only circumstances when information would be shared without your written permission are when there is a clear intention to do harm to yourself or someone else, when your insurance company requests information, or when a court subpoena is issued. In the event of an emergency, I may use my professional judgement to release your personal information as I feel is appropriate to respond to the emergency. In addition to your emergency contact, the police may be notified if I become concerned about your personal safety or the safety of someone else.

I also have a legal and ethical responsibility to notify appropriate agencies of any suspicion of emotional, physical, or sexual abuse or neglect of a child, disabled person, or a person who is over the age of 65.

Adolescent Confidentiality: Adolescents possess some unique rights as it pertains to confidentiality, specifically regarding pregnancy status, status of some sexually transmitted diseases, substance use, and use of oral contraceptives.

Weapons

To ensure a safe and productive treatment setting, I prohibit the possession of weapons of any kind, whether or not a permit to carry is held, in the office or on office property (Penal Law § 265.01-e). This includes firearms, edged weapons, and chemical agents. The only exception to this policy is for on-duty law enforcement officers. Anyone found to be in violation of this policy will be asked to leave the premises.

Recording

You acknowledge and agree that neither you nor I will record any part of your sessions unless both parties mutually agree in writing to do so. You further acknowledge that I object to you recording any portion of sessions without my written consent. You expressly agree that audio and video recordings used for security or legal and documentation purposes are not part of your health records, and are therefore not protected by confidentiality or any other provisions under this agreement.

Notice of Privacy

You have received the Notice of Privacy Practices. As required by law and professional ethics, I keep all patient information in strict confidence as outlined within this policy and procedures document.

Practice Ownership and Organization

I am engaged in an individual practice. I am not part of a group practice. The other physicians in my office suite and I share space but do not share responsibility for patients unless an explicit referral has been made.

Consent for Treatment

I, the undersigned patient or legal guardian, consent to evaluation and medically necessary interventions by Carla Velarde, MD MPD. I understand that I have the right to be informed of and participate in the selection of treatment modalities. I understand I can terminate consent for treatment at any time and that Carla Velarde, MD MPH may terminate consent for treatment at any time.