LHL-Ancillary-Packet Form

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Sessions and payment: The primary mode of treatment is through prescribing psychiatric medications. Psychotherapy may be recommended, if indicated, and you can discuss fees with Dr. Langley at that time.

Please be aware that Dr. Langley is an out-of-network provider for all insurance companies. The office financial policy is to receive payment at the time of service. You are required to keep a valid and active credit card on file in order to schedule an appointment. Upon request, the office will provide you with the information needed to submit an insurance claim. If reimbursement is due, it will be submitted directly to you.

Initial evaluation (45-60 minutes) : $400
Follow up medication management visits (15-45 minutes): $175-255 (depending on time spent and type of visit)

There is an updated fee schedule effective October 1, 2023, for NEW PATIENTS
There is an updated fee schedule effective November 1, 2023, for ESTABLISHED PATIENTS

Office Hours: Monday-Thursday. The first appointment is at 8:30 am and last appointment starts at 3:30 pm.

Psychotherapy: Cost and treatment plan can be discussed with Dr. Langley

Telehealth: Due to the COVID-19 pandemic, I have provided all care via telehealth for more than a year. At this time, I continue to provide services via telehealth; however, in-person visits are an option for vaccinated patients who would prefer to come to the office. Discuss with Dr. Langley

Release of Information: If there are other physicians, therapists, or providers involved in your care, please complete a “Consent for Release of Information” form for each of them.

HIPAA privacy notice: I, the patient or guardian, understand that the “HIPAA Privacy notice” is clearly posted at LH Langley, PLLC, and that I may view and request a copy of it at any time. The HIPAA privacy notice regards the privacy and protections of my treatment information at LH Langley, PLLC. I understand that treatment records are the sole property of LH Langley, PLLC. I have been notified that release/disclosure of information may only occur with consent unless it is an emergency or for other exceptions as detailed in the General Statutes of in 45 CFR 164.512 of HIPAA.

Cancellations: Please allow 48 hours notice for cancellations.You will be charged the entire fee for missed appointments that were not cancelled or were cancelled with less than 48 hours notice. If you have a Monday appointment, you must cancel by Thursday at 5:00 pm in order to avoid being charged for the appointment. My office is closed on Fridays. Cancellations with adequate time allow me to schedule patients who may be waiting for an appointment. You will not be permitted to schedule future appointments until fees/balance has been paid in full.

Termination: Termination of treatment will occur for non-compliance with our treatment plan. Repetitive canceling or missing appointments is treatment noncompliance. Termination of treatment will be immediate for any inappropriate or illegal behavior towards your provider or staff.

Refills: I prescribe medication quantities that align with the treatment plan and frequency of follow up appointments. If you are prescribed a controlled substance, I will not refill these medications early except for appropriate "vacation refills". If you lose your medication (lost, stolen, forgotten on a trip, etc.), you must wait until your next appointment for a refill. I am legally required to see you at least every 3 months to prescribe controlled substances.

Signature of Patient or Legal Guardian

Date

Printed Name of patient

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Recurring credit/debit card payment authorization FORM

Patient Name:

DOB:

Date:

I understand and authorize LH Langley, PLLC to charge the credit/debit card on file the amount due at the time services are rendered. I also understand that this card will be charged the full fee for service if I do not give 48-hour notice of cancellation or if I miss/No Show the appointment. This fee is outlined in the Office Policies Form.

Name On Card:

Mastercard Visa

Credit Card Number:

Expiration Date:

CVV code:

Billing Address:

Billing Zip Code:

Signature of Patient or Legal Guardian

Print Name:

I authorize the above named business to charge the credit/debit card indicated in the authorization form according to the terms outlined above. If the above noted payment dates fall on a weekend or holiday, I understand that the payments may be executed on the next business day. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termation of this authorization at last 7 days prior to the next appointment. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit/debit card and that I will not dispute the scheduled payments with my credit/debit card company provided the transactions correspond to the terms indicated in this authorization from.

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Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the coronavirus. Although we have taken measures to provide social distancing in our practice, social distancing is not possible at all times.

Although exposure is unlikely, do you accept the risk and consent to treatment?

Yes No

Patient Name

Signature of Patient or Legal Guardian

Date

Print Name:

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Patient Name:

Date of Birth:

I hereby authorize:

Name

Address:

Telephone

Fax

AND

LAUREN LANGLEY, DNP, MSN, PMHNP-BC

1017 Ashes Drive, Suite 104: Wilmington, North Carolina 28405

(910) 679-4424 (Phone)

(910) 679-4478 (Fax) *PLEASE FAX

to share information about my treatment plan

This information includes:

Psychological evaluation

Medications

Laboratory reports

Previous notes, medical record

I understand this information will be used for:

Coordination of care

Treatment planning

Evaluation

I understand this information will not be further released without my consent.

I understand that there are regulations protecting the confidentiality of authorized information and I hereby acknowledge that this consent is voluntary and valid for 1 year or until this request is fulfilled. I acknowledge that I may revoke this consent at any time by doing so in writing, knowing that action may have already been taken.

Signature of Patient or Legal Guardian

Date

Print Name:

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Good Faith Estimate for Health Care Services and Items for Self-Pay Patients

Services Provided by Lauren Langley, DNP, MSN, PMHNP-BC NPI: 1104063676
Services Provided at LH LANGLEY, PLLC Office EIN: 46-0725086

Date:

Patient Name:

DOB:

CPT Code(s)-Primary and Secondary

99205 Psychiatric Evaluation $400
99213 Medication Management $175
99214 Medication Management $200
99215 Medication Management $255
90833 Brief Psychotherapy $120
90836 45-minute psychotherapy $200

ICD-10 Diagnostic Code(s): Specific diagnoses discussed during treatment.

F39 (Mood Disorder)
F32.A (Depression)
F41.1 (Generalized Anxiety)
F41.0 (Panic Disorder)
F42.9 (Obsessive Compulsive Disorder)
F40.10 (Social Anxiety)
F90.9 (Attention Deficit Disorder)
G91.3 (Oppositional Defiant Disorder)

*Medication management visits are expected to be recurring. The frequency of appointments and type of appointment may vary based on current needs/symptoms. **This is a detailed list of estimated charges for psychiatric care with Lauren Langley. The estimated costs are valid for 12 months from the good faith estimate.

Disclaimer:
This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created. The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, federal law allows you to dispute (appeal) the bill.

If you are billed for more than this Good Faith Estimate, you have the right to dispute the bill. You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available. You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill. There is a $25 fee to use the dispute process. If the agency reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate. If the agency disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059. For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers or call 1-800-985-3059. Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Signature of Patient or Legal Guardian

Date

Print Name:

Thank you!

office policies

Recurring credit/debit card payment authorization FORM

Supplemental Informed Consent: Treatment in the era of covid-19

CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION

Good Faith Estimate for Health Care Services and Items for Self-Pay Patients