ICHANGE Counseling & Psychiatry Policies

This is not the intake paperwork. Please call 940-448-0304 to make an appointment.

Initial Visit: Your initial visit will include an evaluation and treatment plan/recommendations. Please be aware that the
initial visit is for consultation only and does not necessarily imply a long-term treatment relationship or that medications
will be prescribed. It is important for the provider and patient to meet and mutually agree to continued care. If the
provider determines that they are unable to assist you or that your needs fall outside of the scope of the practice,
attempts will be made to refer you to someone who can. We reserve the right not to reschedule missed intake
appointments. If there is a reschedule, full payment of the visit plus a no show fee is required prior to rescheduling.

Follow up visits: Follow up visits will be necessary to evaluate your response to treatment as well as to continue to
monitor your symptoms. Psychiatric follow-ups generally last 20-30 minutes, and counseling appointments are typically
45-60 minutes. The frequency of these visits will be decided upon by your care needs Any patient suspected to be
intoxicated with any substances during a visit with the provider will not receive treatment. Under no circumstances will a
patient be treated if under the influence. There will be a full fee charge for the reschedule fee. iChange has a legal duty
to inform the proper authorities if it is suspected that the client is in danger of harming one's self or another by driving. A
cab may be called at the expense of the patient.

Telehealth visits: This is not a service we are able to offer for all routine appointments. Payment is due prior to the
visit. When you engage in telehealth visits by discussion you are verbally consenting to service. You may at any time
decline telehealth services by written notice. If an emergency arises during the session, call 911. Visits should be held in
a confidential area and should not be while driving. If a session call / video is dropped, the provider will attempt to call
the patient back once. I understand that iChange will not record my visual or phone sessions, unless there is an explicit
written consent by me for reasons that clearly benefit my treatment. I also understand Dr. Aponte/iChange provider does
not consent to video or audio recording of the telepsychiatry visits. I understand that in the event of an emotional
emergency, and I cannot reach the provider of iChange, I can call 911 or the local emergency response team, go to the
nearest emergency room, or contact the local crisis center. We request you not to be driving during sessions. I give my
consent to use electronic devices and programs for office visits. I understand that private insurances may have different
reimbursements or fee schedules for telepsychiatry/ teletherapy visits. I will be fully responsible for the cost of the visit if
it is not covered by my insurance plan. It is my responsibility to call my insurance carrier and confirm coverage of my
visit costs. I understand Telehealth is not provided across most state lines. Patient / Client must physically be in Texas
during telehealth sessions.

• I have had ample opportunity to ask questions and receive clarification about these options
and this policy, I will comply with the above plans set up to address the potential risks of telepsychiatry and discuss any
aspects that require my participation in the planning, I understand that I have the option to choose which
telecommunication method(s) I prefer, I have “opted in” for the electronic technology that is acceptable to me at this
time, I understand that I have the option to change my mind about any of my choices listed above and I will do so in
writing, I do recognize the potential risk of compromise to my confidentiality by using phone or visual telecommunication
& I wish to proceed knowing these risks and understand I should not be driving during a tele session. I Understand if I
feel unsafe or are in an emergency I will call 911.

No Show/Late Cancellations/Missed or Rescheduled Visits: Our business hours are Monday to Thursday
9:00am-5:00pm, Friday 10:00am-3:00pm. Counselors’ availability will vary based on the provider. iChange reserves your
appointment time only for you. If you are unable to come to your appointment, please give at minimal 24 business hours’
notice (weekends/holidays are not considered business days). If you provide less than 24 hours’ notice you will be
charged. If you have missed 5 or more minutes of your appointment time, the appointment may need to be rescheduled
and it will be considered a “no show” visit and carry a fee range dependent on MD or LPC from $75 to full intake fee up
to $255 +. If you cancel late or no show for your visits more than once, we reserve the right not to reschedule your
appointment. Reminders for appointments may be placed as a courtesy. These communications are not mandatory and
not receiving a reminder does not mean you no longer have an appointment. You will still be responsible for any fees
incurred for missing a visit or not canceling within 24 business hours’ notice. In order to avoid reminder emails from
going into your spam folder instead of your inbox you should add to your list of
authorized emails.

Services not provided: Letters for emotional support or service animals. Specific substance abuse treatments such
as methadone or suboxone. Inpatient treatment (Dr. Aponte does not hold admitting privileges at any of the local
hospitals).Treatments with injectable medications. Disability determinations (short term/long term disability, FMLA leave
from work, or Social Security disability).

Court appearances / legal letters of medical opinions: If a subpoena were to occur and the doctor or staff needs to
appear in court, the patient will be responsible for payment of applicable fees, which may include: $450 provider hourly
fee, $75 staff clerical hourly fee, $135.00 treatment reports, deposition$225 plus applicable charges for medical records
copies/staff hourly preparation fee, $95 for preparation of subpoenaed records, and all legal fees incurred by the
physician, staff or practice for the purpose of complying with the court subpoena or record request. Expedited requests
for records will carry an additional fee of $25. MD rate is $125 more on each court service.
Payment and Fees: Payment for services is expected at the time of service and will be collected prior to your visit. A
payment towards a future session does not guarantee a provider / patient relationship. There is a $55 fee for returned
checks and $5 fee for denied credit cards. Patients are expected to remain up to date on their accounts and pay
outstanding balances in order to schedule appointments. With a signed authorization, iChange may securely store credit
card information, and only charge it should the patient have an upcoming session fee, outstanding balance or any
leftover balance from a processed claim. The patient is responsible for keeping the office updated with current credit
card information. Phone calls with providers over 5 minute will be billed at $2.00 a minute. This could be in addition to
session cost.

GOOD FAITH: iChange will provide you with an invoice good faith estimate per the No Surprise Act. The
estimate could change depending on services rendered, billing, or insurance payments if applicable. Further information
on the No Surprise Act can be found at https://www.cms.gov/nosurprises

Insurance Notice: We are considered an “out-of-network” provider for most all insurances other than BCBS PPO,
including other types of BCBS (ex: HMO) and those who subcontract Mental Health benefits out to other insurance
companies. Patients are responsible for calling their insurance to verify mental health benefits. If insurance denies
payment for any reason (including, but not limited to, an unmet deductible, services are not covered under your policy, or
benefits subcontracted to a third party), you will be responsible for the full price of your visit. Please contact your
insurance company to verify if you will need prior authorization for your visits. In the event that an account is 30+ days
overdue and turned over to our collection agency, the patient or responsible party will be held responsible for any
collection fees charged to our office to collect the debt owed plus a $55 fee. If your account has a credit, we will attempt
to refund you once written notification is received. Unclaimed credits are forfeited after one year of last service date. If
payment is not received as arranged, we reserve the right to contact the parties involved in the collection of payment.
Changes in Fees: We reserve the right to adjust the fees schedule and will provide adequate notice prior to changes
taking effect.

Dr. Aponte & Prescription Refill Requests: You should be aware of the amount of medication you have left and when
you will need a refill. The doctor will prescribe enough medication to last until your next appointment. If you miss or
change an appointment, it is your responsibility to request a refill so that you do not run out of medication. The doctor
may refuse to give a refill if she has not seen you recently and feels that an office appointment is clinically indicated. To
request a refill, please contact your pharmacy first and they will send the electronic request. Please allow 48-72
business hours to process refill requests. Refills are not processed over the weekend or holidays. Insurance
companies will sometimes request a Prior Authorization (PA) before approving your medication. Please allow 72
business hours for the PA to be completed by the doctor. This however does not mean that the PA will be approved
within this time frame; that is determined by the insurance company. With a signed authorization, the patient’s medical
and prescription history will be retrieved via our secure electronic medical record system. This allows us to provide care
in a safe and complete manner. Review of the history of controlled substances prescriptions is mandated by the Texas
Medical Board and does not require signed consent from the patient.

Communicating with the practice: We do our best to always be available to take your call during regular business
hours. We do not hold business hours during evenings, weekends, or holidays In the event you get our voicemail during
business hours and you choose to leave a message with your information, a member of our staff will call you back
promptly. After hours messages will be answered within 48 business hours. Messaging Communication Policy:
Electronic communication is convenient and helps reduce “phone tag”. That said, confidentiality /encryption via
electronic communications cannot be guaranteed. Keep this in mind when sending sensitive information via these
means. The office is not responsible for any security breach although we make every attempt at protecting your
confidentiality. If you initiate communication with the practice electronically, we will take this as an implied consent for
exchange of sensitive information in such a way. Electronic communications with the office are not monitored in real time
and as such, emergencies should be communicated via phone to the office during regular business hours. Dr. Aponte
does not communicate with patients via text due to confidentiality and safety. If you contact iChange or your provider by
any of the above means and don’t receive a response in 72 business hours, please call the office directly.

Emergencies: We will work together to help ensure your safety. We are not a crisis facility. If you are having a crisis or
emergency after business hours please call 911 or go to your nearest emergency room. You may also reach the Crisis
Team at MHMR at 800-762-0157 to speak with an emergency provider after hours and this information is accessible
through our office line after business hours. Vacations and Holidays: As a solo practitioner, Dr. Aponte will have limited
coverage during vacations and holidays. Vacation times for all providers will be announced with enough time so that you
can plan ahead for your appointment, refill requests, etc.

Medical Record Requests, Letter and Forms: Medical record requests require a “Release of Information Form” signed
by the patient in its entirety. Records are sent directly from the iChange office to the requesting physician’s office.
Medical records requested for the patient’s own use carry a charge (35 cents per page, $55 per hour clerical fee) and
may be provided in the form of a treatment summary at the discretion of the physician. Letters and completion of forms
may carry a charge. Expedited requests for records will carry an additional fee of $25.By signing below, you give
consent to iChange and its providers to be custodian of your file and to access it for you if your provider were to become
incapacitated or die. You also give consent for staff to contact you via telephone or email in case of such events.

HIPAA NOTICE OF PRIVACY PRACTICES: The federal government mandated that as of April 14, 2003, all health care
patients are to receive from their clinicians a notice (hereafter referred to as "Notice") regarding the protection of their
private health care information in compliance with the Health Insurance Portability and Accountability Act ("HIPAA")
Privacy Rule (45 C.F.R. parts 160 and 164). This form documents that Dr. Dorian Aponte/ iChange provider has given
you the "Notice" that is required. HIPAA covers what is called "protected health information" (PHI) that is used for
treatment, payment, and health care operations. PHI is information in your health record that could identify you. Each
time you visit the office, a record of your visit is made. This record contains your symptoms, diagnosis, treatment and
plan for future care or treatment. It serves as a basis for planning your care and treatment. However, it also can act as a
legal document describing the care you received and as a means by which you or a third-party payer can verify that
services billed were actually provided. It may also be a means of communicating with other health professionals who
contribute to your care. Understanding what is in your record and how your health information is used helps you to
ensure its accuracy, better understand who, what, when, where and why others may access your health information, and
make more informed decisions when authorizing release to others.

Your Health Information Rights: Although your record is the physical property of iChange, the information belongs to
you. You have the right to: Request restrictions on certain uses of your information, obtain a paper copy of the Notice of
Privacy Practice, amend your health record according to legal protocol, request communications of your health
information by alternative means & revoke your authorization to use your health information except to the extent that
action has already been taken or is required by law. Our Responsibility: Maintain the privacy of your health
information, provide you with a notice as to my legal duties and privacy practices with respect to the information we
collect about you, abide by the terms of this notice, accommodate reasonable requests you may have to communicate
health information by alternative means. We will not use or disclose your health information without your authorization,
except as described in this notice.

Inspections or Copies of Health Information: Health records requests should be made in writing. We can refuse to
provide some of the information you ask to inspect or ask to be copied for the following reasons: the information is
psychotherapy notes, the information reveals the identity of a person who provided information under a promise of
confidentiality, the information is subject to the Clinical Laboratory Improvements Amendments of 1988, or the
information has been compiled in anticipation of litigation. Additionally, if the information in the record could cause
mental harm to you, a summary will be provided instead. Amendment of Medical Information: You may request an
amendment of your medical information in the designated record set. Any such request must be made in writing to the
practice. We will respond within 60 days of your request if able. We may refuse to allow an amendment for the following
reasons: the information wasn’t created by this practice or the physician in this practice, the information is not part of the
designated record set, the information is not available for inspection because of an appropriate denial, or the information
is accurate and complete. Even if we refuse to allow an amendment, you are permitted to include a patient statement
about the information at issue in your medical record. If we refuse to allow an amendment, we will inform you in writing.
If we approve the amendment, we will inform you in writing, allow the amendment to be made and tell others that we
know have the incorrect information.

Examples of Disclosures for Treatment, Payment and Health Operations: iChange will use your health information
to provide treatment. If a third party payer is paying for the bill, then they will get information that identifies you, as well
as your diagnosis and the type of treatment provided. Please note the practice utilizes electronic medical record systems
and others as part of the routine operation of the practice and they may have access to your information (this includes
but is not limited to Practice Fusion, Availity, Google, Square, security cameras in common patient areas, billing and
collections companies). In addition, your provider may be required to disclose health information for law enforcement
purposes, or in response to a valid subpoena, or in relation to a workers’ compensation claim. We will make every effort
to inform you if such a request is made. Your safety is our highest priority. Other contacts may be notified if there is
significant concern for your safety or the safety of others. If feasible, iChange will attempt to get your permission, but this
can be done without your permission or even if you protest, if your safety is at risk. The fewest number of people will be
notified in order to ensure your safety (i.e., your place of employment or neighbors would be notified only if their
notification would be of immediate benefit to you or someone else).

Other Disclosures Required by Law: Because Texas law requires physicians to report child/elder abuse or neglect,
we may disclose medical information to a public agency authorized to receive reports of child/elder abuse or neglect.
Texas law also requires a person having cause to believe that an elderly or disabled person is in a state of abuse,
neglect, or exploitation to report the information to the state, and HIPAA privacy regulations permit the disclosure of
information to report abuse or neglect of elders or the disabled.

Complaints, Contact for Requests or Records, and Grievance Policy: iChange Counseling and Psychiatry and its
providers are committed to providing the highest quality of services to all clients. If a person receiving services is not
satisfied with the services being provided or experiences a situation that cannot be resolved satisfactorily between
themselves and iChange provider / staff.

Grievance Steps
1. In writing submit a statement of grievance to iChange at

2.Confirm statement is received with the office by calling 940-448-0304. 3. Give 60 days for
iChange to achieve a satisfactory resolution. In the event that a satisfactory resolution cannot be achieved, the client
reserves the right to file a grievance with the Texas Department of State Health.
Texas Department of Health and Human Services and/or the licensing board
Texas Behavioral Health Executive Counseling
George HW Bush State office Bldg,
1801 Congress Ave, Ste 7.300 , Austin TX 78701

Texas Medical Board, 333 Guadalupe
Tower 3, Suite 610, PO Box 2810, MC263
Austin, TX 78768-2018 1-80-201-9353

CONFIRMATION OF POLICIES: I am aware of the service fee schedule. I understand payment for services is expected
is to be collected prior to my visit. Payment does not guarantee provider (doctor) - client ( patient) relationship. Intake
paperwork does not guarantee relationship. I am aware insurance may not pay for all services rendered and that I am
100% liable for any amount the insurance does not pay. Mental health coverage could be contracted out to a 3rd party
that iChange is not on panel with. Patient / client is responsible for verifying benefits and will be prepared to pay in full. I
am aware that I am responsible for the $75-full intake fee applied to no show visits and for appointments canceled with
less than 24 business hours’ notice. Weekends and Holidays are not business days. I am aware that payment is due for
all services rendered at the time of the appointment. I agree to pay any outstanding balances, attached fees for late
payments ($25), bounced checks ($55), and no show / late-cancel fees ($75 - full fee) prior to the next appointment. Any
intake appointments that are canceled in less than 24 hours or are not attended at all the full payment is relinquished as
part of our policy. Reimbursement checks need to be deposited within 30 days or they will be voided. I authorize
iChange to securely store my credit card information, and only charge it should I have an outstanding balance or any
leftover balance from a processed claim in the future. I am responsible for keeping the office updated with current credit
card information. I understand that though iChange secures information, the web can be unsafe. In the case a payment
is made over the phone, I agree to my credit card information being collected, entered, and processed.
-I am aware Dr Aponte / iChange are not Medicare / Medicaid providers and are not bound to Medicare fee limitations.
Payment and claims will not be submitted by iChange office nor myself to Medicare.
-I understand that proper follow up is required for medications to be prescribed or refills authorized. I also understand
that prescriptions need to be requested 48-72 business hours in advance before they are due to ensure our office and
the pharmacy have enough time to process my request. Weekends and holidays are not business hours
- I agree to communication via Phone, Voicemail, Text, Email, and Patient Portal, video or teletherapy sessions, although
encryption cannot be guaranteed. If I oppose one of these, I will provide written notification. This consent overrides any
consent provided in all previous year’s versions of office paperwork. -I understand this office works on an appointment
basis therefore calls, emails, or other communication is handled within 48 business hours. I understand iChange is not a
crisis clinic and staff does not return calls after hours. Please call 911 or go to the ER in case of emergencies. I authorize
retrieval of my medical and prescription history via the practice’s electronic medical records system.
-I understand the members of the office staff have associate agreements to protect my privacy and abide by the privacy
act and will not share my confidential information. I am aware and understand that weapons of any kind, with or without
a license to carry, are strictly prohibited on our premises. iChange does enforce penal codes 30.06-30.07. Video or
audio recording of sessions is also prohibited.
-I am aware of the No Surprises Act and understand I can receive another printable notice from www.ichangetx.com or
https://www.cms.gov. The good faith invoice with iChange business does not expire. It is simply updated.
-If I have not been seen for a visit in 10-12 months or more, my care will be administratively inactivated and iChange will
no longer be my provider. If I wish to reestablish care, I will need to schedule a new patient visit. If I wish to terminate my
care, I will do so in writing by contacting --My name and electronic signature below are considered
to be my legal signature. I am aware my consent to all above policies do not end in a year but when I give written notice
of changes to iChange staff