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Privacy Notice

The following section details Pine Ridge Mental Healthcare's professional services, policies, consents, emergency procedures, notice of privacy practices, and patient rights & responsibilities.

Practice Policies and Procedures

Welcome to Pine Ridge Healthcare!  Please read the following information carefully so you have a clear understanding of our policies concerning communication, fees, insurance, confidentiality, etc. This acknowledges that we have provided you the opportunity to review our Practice Policies and Procedures as is required by federal law. Please take your time to review and fully understand this document. Your agreement to the following terms and conditions is required for you to receive professional services from us. If you do not agree, I will be glad to give you referrals to other providers.

Professional Services

Services include assessment, diagnosis, on-going medication management, and  psychotherapy. At the conclusion of your first visit, your provider will share their thoughts on your diagnosis, answer your questions, and discuss potential evidence-based treatments. You will then mutually decide whether or not to continue treatment.  An appointment guarantees time with the provider, it does not guarantee prescribing of specific or requested medications, treatments, or writing of letters.  Your provider does not provide forensic services such as custody evaluations, assessments recommended by probation, ability to stand trial, legal matters of medical opinion, etc. Your provider will not fill out paperwork for any organization unless you have been a patient for at leas six months OR you have been seen a minimum of 6 times. 


In some situations, Pine Ridge Healthcare may not be able to meet your health needs, and we will give you information where you can obtain care elsewhere. Additionally, if you feel that we are not well matched to your needs, we will be happy to provide you referrals to other health professionals. By signing this consent, you agree not to record  visits, in part or whole, by any recording means available.

Consent for Treatment

All medical and therapy treatment is strictly voluntary, and you may choose to stop treatment at any time you wish. If you experience any problem(s) with medication and/or therapy, it is your responsibility to inform your provider of the problem(s).

All medical and therapy treatment is strictly voluntary, and you may choose to stop treatment at any time you wish. If you experience any problem(s) with medication and/or therapy, it is your responsibility to inform your provider of the problem(s).

Office Hours, Appointments, and After Hours Policy

Office hours in general are M-F between 9:00 am- 5:00 pm.  Federal holidays are observed.  Pine Ridge Mental Healthcare complies with HIPAA and wants to exchange text messages with you. Text messaging may not be fully secure. By signing this agreement, you are giving consent to text-messaging from Pine Ridge Mental Healthcare. To opt-out please inform the receptionist to receive an opt-out form. 


Appointments are scheduled to begin and end on time, which means your session time is reduced if you are late in arriving.  


Different people react differently to the same treatment, and it is important to let your provider know about any difficulties or discomfort you are experiencing with medications.  Please leave a message via Charm and a provider will return your message within 48 hours.  Your provider will evaluate symptoms and side effects with you by phone, briefly, at no charge.  If the discussion is complex, you will need to make an appointment. If  a more lengthy telephone discussion is required (10 minutes or more), or frequent short phone calls (3 or more in one month), you will be charged for the time at the same rate as appointment time, with a minimum of $25.00.


You may call and leave a non urgent message or text at any time.  Someone will get back to you as soon as  available, usually within two business days. If waiting for a response from someone is not in your best interests, you agree to contact other providers involved in your care such as your therapist, primary care physician, local emergency room or a 24 hour crisis team at 1(800) 273-8255. In the event of a life threatening medical emergency, call 911 or go to the nearest emergency room.

Medication Prescriptions and Refills

In order for your provider to properly prescribe medication for you, you consent for Pine Ridge to retrieve your medication history from an online clearinghouse such as Surescripts.


You will be provided with enough medication until your next recommended follow up visit. It is your responsibility to make your own appointment on time so you do not run out of medication. Your provider may not be able to respond to such request for up to 2 business days, so please plan accordingly.


Please let your provider know of any new medications, supplements, or over the counter medications you start or stop during our treatment. It may take up to 48 hours for initial and follow up prescription medications to be at your pharmacy, so please plan accordingly.

Laboratory Studies and Additional Testing

Various diagnostic studies, laboratory studies, and imaging may be recommended or required for the best possible care. Completion of necessary lab work may be required prior to initiating or continuing medication. Please be aware that the costs of these diagnostic studies is not included in your visit charges, and are your sole responsibility.

Additional testing may include ECG, MRI scans, referral for additional testing, and the monitoring of vital signs. All patients on medication require vital signs to be followed, and you agree to provide the necessary information accordingly.

Cancellation Policy

Please give at least 24 business hours (M-F) notice of cancellation if you cannot make an appointment. For less than 24 hours cancellation notice or not showing for your appointment, you will be charged $75. If you give less than 24 hrs notice and/or no-show for 3 appointments in 6 months, you may be released from the practice. You will receive a reminder by text, voice, or email (per your preference) up to 48 business hours before your appointment.


If you have not completed your required patient questionnaire(s) within 1 calendar day before your appointment, your appointment slot may be automatically cancelled, and you will need to reschedule.

Professional Fees and Credit Card Policy

Payment is due at the time of service.  Signing below acknowledges Pine Ridge Healthcare LLC requires a credit or debit card on file for all services. Your card will NOT be charged without your permission, EXCEPT in the following cases:

1. Late cancellations or appointment no-shows

2. Your bill is more than 60 days past due, without alternative payment arrangements in place.


You understand that your information will be saved for future transactions.  You hereby give authorization for any card on your account to be charged for any current, recurrent or past due balances on an on-going basis.  This permission will continue until cancelled in writing.  You understand that your provided card on file will be the preferred method of payment.


Pine Ridge Healthcare does participate in several insurance panels. However, if we do not currently participate in your particular insurance panel, we will be happy to provide a statement that you may submit to your insurance company for out-of-network care.

Telehealth Consent

Telemedicine involves the use of electronic communications to enable healthcare providers at different locations to share individual patient medical information for the purpose of improving patient care. Telemedicine services offered may also include chart review, remote prescribing, prescription refills, appointment scheduling, health information sharing, and non-clinical services, such as patient education. The information you provide may be used for diagnosis, therapy, follow-up and/or patient education, and may include any combination of the following:

(1) health records and test results;

(2) images;

(3) live two-way audio and video;

(4) interactive audio; and

(5) output data from medical devices and sound and video files.

The electronic communication systems we use will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

Pine Ridge Healthcare providers are an addition to, and not a replacement for, other providers caring for you. Responsibility for your overall medical care should remain with your local primary care provider, if you have one, and we strongly encourage you to locate one if you do not.

Benefits of Telemedicine

Telemedicine stands at the crossroads of cutting-edge technology and formal health services. You can expect the following benefits:

1) Telemedicine eliminates barriers to accessing healthcare and provides an alternative means to obtain health services for patients who may otherwise have limited accessibility or encounter prolonged waiting lists in the community.

2) In addition to removing the burden of travel time to a physical medical office as well as the risks and costs associated with transportation,Telemedicine allows for flexible scheduling.

3) Telemedicine offers a reduction of stigma by providing private treatment in the comfort of a patient’s personal space.

4) Telemedicine can provide treatment to patients with disabilities and limited mobility without requiring extensive planning for transport.

Limitations of Telemedicine

While it is not possible to anticipate all the limitations of any treatment, you should consider the following when consenting to treatment via Telemedicine:

1) Telemedicine audiovisual equipment may experience technical difficulties.

2) While every precaution is taken to secure patient data and maintain confidentiality, the nature of electronic appointments results in additional exposure to security breaches.

3) Telemedicine may not be suitable for certain illnesses that require higher levels of care.

4) Certain illnesses may not be adequately treated by Telemedicine.

5) Certain conditions or side effects from medications might not be adequately assessed through Telemedicine.

6) In very rare events, security protocols could fail, causing a breach of privacy of personal medical information.

7) In rare events, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

What To Do In An Emergency

What can I expect if I need to discuss a medication in between telemedicine visits?

You will need to contact Pine Ridge Mental Healthcare to schedule a walk-in visit or speak directly with the telepsychiatry provider.


What is a mental health emergency?

There are several things that may be considered a mental health emergency.

1. Having thoughts of wanting to harm yourself or harm others, especially when:

These are new thoughts.

You feel you may act on these thoughts

You begin to make plans to carry out these thoughts.

2. Being unable to take care of your basic needs (such as food, shelter, clothing) because of the state of your mental health, e.g., feeling so sad that you are unable to eat

3. Having a severe reaction to a medicine that the telepsyciatric clinician has prescribed for you; for each medication that the telepsychiatric clinician recommends you take, (s)he will inform you of the signs of a serious reaction, and what you should do about it.

4. Other thoughts or behaviors not described above where you feel that yourself or others may be in danger or be harmed because of a mental or medical condition; remember, it is always better to be safe, and seek help and advice when you are unsure if you are having an emergent mental health or medical condition than to try and handle a situation by yourself.

What should I do in the case of an emergency?

This clinic is taking place by telehealth (live interactive video conferencing). The clinic staff and the telepsychiatric clinician will not be available for emergency care except during scheduled clinic hours. The local hospital will provide emergency services and care for patients involved in this clinic. If, at any time, you feel you are having an emergency due to a mental health condition, you need to contact your local hospital and ask for the ER. When connected with the ER, explain your situation and ask for Mental Health Emergency Services. You may also go directly to the ER. Please remember to tell the Emergency staff that you are receiving treatment through this clinic and inform them of any medications you are taking. If you have any contact with emergency services, at your earliest opportunity, please call Pine Ridge Mental Healthcare so they are aware of what is occurring.




 Pine Ridge Healthcare (PRH) understands that health information about you and your health care is personal. It is committed to protecting health information about you. A record of the care and services you receive from the clinic is created. This record is to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this healthcare practice. This notice will tell you about the ways in which Pine Ridge Healthcare may use and disclose health information about you. It also describes your rights to the health information kept about you and describes certain obligations we have regarding the use and disclosure of your health information. Law requires to:

•    Make sure that protected health information (“PHI”) that identifies you is kept private.

•    Give you this notice of the legal duties and privacy practices with respect to health information.

•    Follow the terms of the notice that is currently in effect.

•    PRH can change the terms of this Notice, and such changes will apply to all information about you. The new Notice will be available upon request, in the office and on the website.


The following categories describe different ways that PRH uses and discloses health information. For each category of uses or disclosures PRH will explain what is meant and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways PRH is permitted to use and disclose information will fall within one of the categories.

For Treatment Payment, or Health Care Operations: Federal privacy rules (regulations) allow health care providers who have direct treatment relationship with the patient/client to use or disclose the patient/client’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. PRH may also disclose your protected health information for the treatment activities of any health care provider. This too can be done without your written authorization. For example, if a clinician were to consult with another licensed health care provider about your condition, we would be permitted to use and disclose your person health information, which is otherwise confidential, in order to assist the clinician in diagnosis and treatment of your mental health condition.

Disclosures for treatment purposes are not limited to the minimum necessary standard. Because therapists 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 providers with a third party, consultations between health care providers and referrals of a patient for health care from one health care provider to another.

Lawsuits and Disputes: If you are involved in a lawsuit, PRH may disclose health information in response to a court or administrative order. It may also disclose health information about your child in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.


1.    Psychotherapy Notes. PRH does keep “psychotherapy notes” and “therapy notes” and any use or disclosure of such notes requires your Authorization unless the use or disclosure is:

a. For use in treating you.

b. For use in training or supervising mental health practitioners to help them improve their skills in group, joint, family, or individual counseling or therapy.

c. For use in defending PRH in legal proceedings instituted by you.

d. For use by the Secretary of Health and Human Services to investigate PRH compliance with HIPAA.

e. Required by law and the use or disclosure is limited to the requirements of such law.

f. Required by law for certain health oversight activities pertaining to the originator of the psychotherapy notes or therapy notes.

g. Required by a coroner who is performing duties authorized by law.

h. Required to help avert a serious threat to the health and safety of others.

2.    Marketing Purposes. PRH will not use or disclose your PHI for marketing purposes.

3.    Sale of PHI. PRH will not sell your PHI in the regular course of business.


Subject to certain limitations in the law, PRH can use and disclose your PHI without your Authorization for the following reasons:

1.    When disclosure is required by state or federal law, and the use or disclosure complies with and is limited to the relevant requirements of such law.

2.    For public health activities, including reporting suspected child, elder, or dependent adult abuse, or preventing or reducing a serious threat to anyone’s health or safety.

3.    For health oversight activities, including audits and investigations.

4.    For judicial and administrative proceedings, including responding to a court or administrative order.

5.    For law enforcement purposes, including reporting crimes occurring on the premises.

6.    To coroners or medical examiners, when such individuals are performing duties authorized by law.

7.    For research purposes, including studying and comparing the mental health of patients who received one form of therapy versus those who received another form of therapy for the same condition.

8.    Specialized government functions, including, ensuring the proper execution of military missions; protecting the President of the United States; conducting intelligence or counter-intelligence operations; or, helping to ensure the safety of those working within or housed in correctional institutions.

9.    For workers’ compensation purposes. 

10.    Appointment reminders and health related benefits or services. PRH may use and disclose your PHI to contact you to remind you that you have an appointment. It may also use and disclose your PHI to tell you about treatment alternatives, or other health care services or benefits offered.


Disclosures to family, friends, or others. PRH may provide your PHI to a family member, friend, or other person that you indicate is involved in your care or the payment for your health care, unless you object in whole or in part. The opportunity to consent may be obtained retroactively in emergency situations.


1.    The Right to Request Limits on Uses and Disclosures of Your PHI. You have the right to ask not to use or disclose certain PHI for treatment, payment, or health care operations purposes. PRH is not required to agree to your request, and may say “no” if the clinic believes it would affect your health care.

2.    The Right to Request Restrictions for Out-of-Pocket Expenses Paid for In Full. You have the right to request restrictions on disclosures of your PHI to health plans for payment or health care operations purposes if the PHI pertains solely to a health care item or a health care service that you have paid for out-of-pocket in full.

3.    The Right to Choose How PRH sends PHI to You. You have the right to ask PRH to contact you in a specific way (for example, home or office phone) or to send mail to a different address, and PRH will agree to all reasonable requests.

4.    The Right to See and Get Copies of Your PHI. Other than “psychotherapy notes,” you have the right to get an electronic or paper copy of your medical record and other information on file about you. PRH will provide you with a copy of your record, or a summary of it, if you agree to receive a summary, within 30 days of receiving your written request, and PRH may charge a reasonable, cost based fee for doing so.

5.    The Right to Get a List of the Disclosures PRH has made. You have the right to request a list of instances in which PRH has disclosed your PHI for purposes other than treatment, payment, or health care operations, or for which you provided an Authorization. PRH will respond to your request for an accounting of disclosures within 60 days of receiving your request. The list will include disclosures made in the last six years unless you request a shorter time. PRH will provide the list to you at no charge, but if you make more than one request in the same year, PRH will charge you a reasonable cost based fee for each additional request.

6.    The Right to Correct or Update Your PHI. If you believe that there is a mistake in your PHI, or that a piece of important information is missing from your PHI, you have the right to request that PRH correct the existing information or add the missing information. PRH may say “no” to your request, but will tell you why in writing within 60 days of receiving your request.

7.    The Right to Get a Paper or Electronic Copy of this Notice. You have the right get a paper copy of this Notice, and you have the right to get a copy of this notice by e-mail. And, even if you have agreed to receive this Notice via e-mail, you also have the right to request a paper copy of it.

This notice went into effect on 03/30/21

Acknowledgement of Receipt of Privacy Notice

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use and disclosure of your protected health information. By electronically signing the box below, you are acknowledging that you have received a copy of HIPAA Notice of Privacy Practices.




Treat the staff with consideration, respect and dignity.

Understand that your life-style does affect your health.

Take an active part in your health care.

Follow the agreed upon treatment plan.  If you choose or are unable to follow the treatment plan, it is your responsibility to inform the Medical Provider.

Observe facility rules and regulations that are for the safety and consideration of all patients and staff.

Provide accurate and complete information about present complaints, past illnesses, hospitalizations, medications, advance directives (living wills or durable power of attorney), and other matters relating to your healthcare.

Report whether you understand a contemplated course of action and what is expected of you.




Be treated with consideration, respect and dignity;

Have the confidentiality of your medical information protected, to have privacy act regulations enforced, and to have these areas of confidentiality explained to you in language you can understand;

Have privacy during case discussion, counseling & treatment; 

Review your records in the presence of a healthcare professional;

Know the name and qualifications of staff providing your care;

Know your diagnosis, health problems, test results, the potential advantages and risks of treatment or procedures in language you can understand;

Expect that all services, treatment and counseling techniques will take place with your informed consent;

Participate in referral planning;

Have access to the patient comment procedure;

Refuse to participate in research.

Have another individual present in the exam room with you, if you so desire.

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