Pamela Moore PMHNP LLC
Instructions for getting to Pam Moore’s Tigard office
At the corner of Greenburg Rd. and 217 near Washington Square
9600 SW Oak St.
Our office is in a 5-story, white building that is south of Washington Square. The building is easily visible from North-bound 217 exit ramp, which the building is immediately next to.
On the other side of this building, away from the expressway, are Gustav’s and Red Lobster Restaurants and the tall, Lincoln Tower Buildings. It is easiest (the first time) to reach our office by driving all of the way through the restaurant parking lots to the other side, at which point, our building is in front of you.
There may be a $200 charge for a missed appointment by a patient. Two missed appointments in a calendar year may result in termination of service.
If I can’t make it to an appointment, I plan to text patients that are scheduled that day to that effect; so please check for texts prior to coming to an appointment.
An hour is allowed for appointments. A missed hour is valuable time lost, time which could have gone to a different patient. Therefore, as discussed in the contract, notice via texting to 503-960-3334 must be given if you are cancelling an appointment. If notice is received before 8PM the day previous to the appointment the $200 fee is waived.
Some clients have cited difficulty getting to this office because of transportation problems. If you have car/bus problems, consider calling a taxi, Uber or Lyft. A round-trip fare will likely be less than $200.
Snow days: Check for Portland Public School closures. If either Jackson Middle School is closed or a school near where you live, then appointments are cancelled and there is no charge for missed appointments, but still text me.
A courtesy, text reminder of an appointment is generally sent to patients the previous day by this office. But, ultimately, remembering appointment times is a patient’s responsibility.
Thanks for your consideration,
Please sign and date this form to acknowledge that it is understood. Please feel free to ask questions.
Name: ___________________________ Signature: ________________________
Email and Texting Risk Information
a) Texts and emails are enormous time savers and conveniences. That is clear given that more than 16 million texts are sent per minute worldwide and 320 billion emails per day.
b) And most practitioners and clients like communicating via texting and email. But we have found that normal HIPPA compliant communication—which requires specific URLs and passwords and a learning curve--inhibits important and/or sometimes life-saving communication. This is why I ask for clients to sign an authorization to use normal texting and email.
c) That being said, there are practical, security and professional considerations to keep in mind.
d) First, please respect your providers time and livelihood. Providers earn their living during appointments with clients. Texting or emailing clients is above and beyond requirements of their job. Please do not ask questions that require detailed answers. Keep your texts and emails short and to the point. Don’t be offended if they do the same or ask you to schedule an appointment to discuss matters.
e) How quickly do you normally receive replies from others via email? Do you expect replies more quickly than your therapist’s stated response time? Can you see or feel any negative consequences occurring if your therapist does not or cannot reply to an email as quickly as others in your life typically do?
f) Chances are that you would not even care if someone saw that you had a reminder of an upcoming appointment or that you requested a medication refill. But let your therapist know if you wish to limit electronic communication with him or her.
g) Recognize security concerns of cell phone or on-line communication, including teletherapy. The likelihood of these things being monitored closely by unknown individuals is slight. The risk is greater that they are monitored by computers for trends and marketing purposes; or by known individuals.
h) Take personal responsibility for the security of your equipment and the content of your electronic communication. Start with the ASSUMPTION THAT IT WILL BE SEEN BY OTHERS. Recognize the harm that can be caused to you or others by texting or emailing certain things and DON’T DO IT. Do not use your social media, texts or emails to slander, libel, or attempt to do harm to others. Maintain a high moral ground, courtesy, and good manners.
i) Think about where you read and write emails and texts and what devices you do that on. Think about who can see what you read and write in these places, and who can access the devices you use.
j) If you have sensitive communications that need to be done as part of the therapeutic relationship, do it in the privacy of the practitioner’s office.
k) If you have minors in your household, consider doing your own monitoring with some of the excellent apps that can be used to monitor and protect minors. But be aware that others, who have access to your computer or cell phones can install such software on them. If you are concerned about having your own cell phone or email being monitored, it is recommended that security software or apps be installed; along with secure password, fingerprint IDs, spam blockers, etc.
l) And understand that technical experts often describe email as being like a postcard, in that it can be viewed by all hands it passes through. Add the caveat of `if they were interested…’ Are you familiar with the risks of emails being viewed by various engineers, administrators, bosses, subordinates, and bad actors?
m) Think about which email address(es) you might use with your therapist. Who has access to each address? If you use a work email address or equipment, know that your employer may legally view all the communications you send or receive. Be aware that engineers and administrators at your email service provider may be able to view your emails. If you work in a secure facility or for the government, communication may be actively monitored.
n) Note that there are some interesting effects depending on what devices you and clients use. For example, if your client and you both use iPhones, then your text messages may not be typical SMS text messages. Instead, your messages may be iMessage chats. On iPhones, iMessage chats are colored blue, while classic SMS text messages are colored green.
Credit Card Authorization Form Communication Disclosure
Please Be Aware of the Following:
We have a duty to uphold your confidentiality, and thus we wish to make sure that your use of payment services is done as securely and privately as possible.
After our offices automatic debits to your credit or debit cards, the service may result in receipts for payment being sent to you via email or text messages.
It is possible the receipt may be sent automatically, without first asking if you wish to receive the receipt. We are unable to control this in many cases, and we may not be able to control which email address or phone number your receipt is sent to.
So before authorizing automatic deductions from your credit card(s), please think about these questions:
· At which email address or phone numbers have I received these kinds of receipts before?
· Are any of those addresses or phone numbers provided by my employer or school? If so, the employer or school will most likely be able to view the receipts that are sent to you.
· Are there any other parties with access to these addresses or phone numbers that should not be seeing these receipts? Would there be any danger if such a person discovered them?
In addition to these possible emails or text messages, payments made by credit card will appear on your credit card statement as being made to the practitioner whom you are seeing. Please consider who might have access to your statements before making payments by credit card.
Health Savings Accounts and Flexible Spending Accounts
If you are using a Health Savings Account (HSA) or Flexible Spending Account (FSA) payment card, please be aware that even if your payment goes through and is authorized at the time that we run your card, there is a possibility that your payment could later be denied. In the event of this happening, you are responsible for ensuring that full payment is made by other means.
Tigard Therapy Center Communications Policy
We do not provide 24 hour coverage of client communication. When you need to contact someone who works within the Tigard Therapy Center DBA, these are the most effective ways to get in touch in a reasonable amount of time:
· By phone (503-206-5578) You may leave messages on the voicemail, which is confidential.
· By non-confidential text message (see below for details.)
· By non-confidential email to your therapist or PMHNP (see below for details.)
If you wish to communicate with one of us by non-confidential email or non-confidential text message, please understand about the potential confidentiality risks of doing so and read and sign the Authorization for Transmission of Protected Health Information by Non-Secure Means included with these office policies.
Refrain from making contact using social media messaging systems, such as Facebook Messenger or Twitter. These methods have very poor security and we do not watch them for important messages from clients.
We are unlikely to respond to your requests for medication refills, messages and calls immediately. For voicemails and other messages, you can expect a response within two business days (holidays and weekends are excepted from this timeframe.) I may occasionally reply more quickly than that or on weekends, but please be aware that this will not always be possible.
Be aware that there may be times when we are unable to receive or respond to messages, such as when out of cellular range or out of town.
If you are ever experiencing an emergency, including a mental health crisis, please call one of the support numbers on the attached sheet or go to a hospital emergency room.
If you need to contact one of us about an emergency, the best method is those listed above—phone, voicemail, text message, or email.
Please note that SMS (normal phone text messages) are not designed for emergency contact. SMS text messages occasionally get delayed and on rare occasions may be lost. So, please refrain from using SMS as your sole method of communicating with me in an emergency.
Disclosure Regarding Third-Party Access to Communications
Please know that if we use electronic communications methods, such as email, texting, online video, and possibly others, there are various technicians and administrators who maintain these services and may have access to the content of those communications. In some cases, these accesses are more likely than in others.
Of special consideration are work email addresses. If you use your work email to communicate with me, your employer may access our email communications. There may be similar issues involved in school email or other email accounts associated with organizations that you are affiliated with.
Additionally, people with access to your computer, mobile phone, and/or other devices may also have access to your email and/or text messages. Please take a moment to contemplate the risks involved if any of these persons were to access the messages, we exchange with each other.
Note that Tigard Therapy Center is a DBA, not a business entity. All practitioners at this office have independent businesses and none are responsible for the actions of others.
Non-secure Communication authorization
Tigard Therapy Center is a DBA for the independent practitioners Dr. Leslie Carter; Pamela Moore; Kathy Hardie-Williams; and Eric Morris.
This authorization allows the convenience of transmitting protected health information by non-secure media, including but not limited to un-secured cell phones; un-encrypted texting; un-encrypted emailing; USPS; voice mail; and faxing.
Protected health information is defined by the Health Insurance Portability and Accountability Act (HIPPA) and includes genetic test results and blood test results; medication regimens; as well as other physical and mental health records; health care treatments; information related to the scheduling of meetings or other appointments; and information related to billing and payment (but not to include any financial or claims-related identifiers including, but not limited to, credit card numbers, insurance plan numbers, diagnosis codes, or procedure codes.)
Information concerning your legal rights to not allow non-secure transmissions under HIPPA is available upon request. See the form titled “Tigard Therapy Center Communications Policy” for risks involved with non-secure transmissions.
I have been informed of the risks, including but not limited to lack of confidentiality in treatment, potentially resulting from transmitting my protected health information by unsecured means. I understand that I am not required to sign this agreement in order to receive treatment. I also understand that I may terminate this authorization at any time.
Authorization for Transmission of Protected Health Information by the following Non-Secure Means between practitioners and administrative staff of Tigard Therapy Center and the primary patient contact, who is identified as:
_____________________________ _____________________ _____________________
(name of responsible party) (responsible party email) (responsible party cell phone)
(responsible party signature)
(Signature of client) (Date)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
If you do NOT give permission for Non-secure transmission of information, sign below:
(Signature of client) (Date)
Contract, Office hours, Scheduling Procedure and Financial Agreement
Pam Moore PMHNP LLC
9600 SW Oak St., Suite 525, Tigard, OR 97223
Usual office Hours: Monday-Wednesday 10:30 PM to 4:30 PM
To schedule an appointment call 503-206-5578 during normal office hours
For general questions and requests for medication changes: Email firstname.lastname@example.org or text 503-960-3334
Medication Concerns: Contact your pharmacy to request refills on all but controlled medications (such as stimulants). Your pharmacy is responsible for then contacting me to authorize prescription refills.
Please provide two business days (does not include weekends or holidays) to receive a response to refill requests.
Pam Moore PMHNP LLC does not provide emergency services.
Communicating with me: When you use email ALWAYS provide your full name in it. Do not assume that I recognize you by your email name. Please study the Tigard Therapy Center Communications Policy and the Authorization for Transmission of Protected Health Information by Non-Secure Means. Because people in crisis or who have functional limitations have difficulty dealing with technology and because client’s may hesitate to make requests when faced with logons, passwords, and other issues with email, texting, and other forms of modern communication, I request, but don’t require, that you allow non-secure communications methods in accordance with the Policy and Authorization forms.
I have found voice recordings to be unreliable, incomplete, and difficult to understand, which is why I prefer email, though recognizing that email may fail at times. I will attempt to reply to emails within 48 hours, excepting weekends. If you don’t receive a reply by then please call 503 206 3334. Understand that as an independent practitioner I am subject to illnesses, emergencies and vacations that may interfere with a prompt response.
All of my clients are expected to have email accounts and use this medium as the primary method of communicating with me when necessary. Do not contact me in any way for emergencies as I am often not available.
For emergencies: Call the crisis line at 503-988-4888; or call 911; or go to the nearest hospital emergency room.
Rights and Risks
· Please feel free to ask questions about any aspect of the counseling process.
· If you have been referred by a court or state agency, you have the right to divulge only what you want to have included in the report.
· You need to be willing to discuss what troubles you and be open to change.
· Information shared will be held in confidence.
· Information will not be released without your written consent, except for professional consultation if needed and unless required by law.
· I am requested by law to disclose information pertaining to suspected child abuse; inability to care for one’s basic needs for food clothing or shelter; and threatened harm to oneself or others.
· The courts may, in select cases, subpoena counseling records.
· It is understood that information regarding treatment and diagnosis may be provided to an insurance company and/or an insurance company appointed auditor.
· You may want to discuss further limits or exceptions of confidentiality.
· You have the right to request a restriction or limitation on the health information that I disclose about you to other entities, in which case you may be responsible to pay in full for the services provided.
· You have the right to request the content of our meetings not be documented, in which case you may be responsible to pay in full for the services provided. Check with your insurance provider as to whether they will refuse payment upon discovering, for example, during an audit, that detailed records were not kept.
· All office visits are by appointment only. Please arrive on time, as you use up your own time when you arrive late for an appointment. The usual length of time for an appointment is 60 minutes.
· Cancellation is done by calling our scheduling line at 503-206-5578. A message can be left at this number. Provide and spell your name and give your birth date, if leaving a message. If done in less than 24 hours before the scheduled appointment time and/or if you don’t arrive for your appointments, the appointment is billed to the client for the allowed amount. Insurance companies will not pay for no show or late cancellation charges or for telephone consultations. These are the responsibility of the client.
· We will bill your insurance company for services provided.
· Irrespective of whether the client has insurance or not, the client is responsible for the fees owed.
· In the case of the client having insurance, the client portion of fees is expected at the time of service. Generally, but not exclusively, this includes co-pay and/or deductible. If client’s yearly deductible has not yet been met, the entire session fee is due at the visit.
· Your health insurance may help you recover some of your costs. We may help you determine the amounts. However, it is your ultimate responsibility to determine with your insurance company how much you are responsible to pay and how many sessions you can have within a given period. Please verify with your insurance company the amounts of coverage for outpatient services. This should be done by the client before each visit to assure that you don’t bear an unexpected expense.
· If your insurance policy requires pre-authorization to receive services, this is your responsibility and needs to be handled prior to your first visit.
· You will receive a statement each month that you have a balance due. Moneys thirty days past due will be charged 1.5% interest monthly until paid. This office does not accept responsibility for collecting your insurance claims or for negotiating a settlement on a disputed claim. To clarify, you are responsible for payment on disputed claims.
· If accounts are 90 days in arrears, all client services are terminated. This means, among other things, that no refill requests will be authorized. Clients are expected to find other and/or new providers before reaching this point. Note: discontinuing some medications can have serious and possibly fatal results. If a client cannot pay for services with me, they may seek other community resources before my services are discontinued.
· Clients paying on a cash basis and not billing insurance companies are expected to pay in full at the time of service, unless a payment plan has been previously arranged.
· Phone calls & emails may be billed at $10 for every five minutes that it takes me to respond to them. Client, not insurance companies, are responsible for paying for this. Client must understand that my responding to phone calls, voice mail and emails is an exceptional service that lies beyond that required by law or insurance companies.
· Pam Moore PMHNP LLC reserves the right to release an account to collections for non-payment.
· Letter writing, filling out forms, and doing prior authorizations will be billed as specified below. These charges may not be recoverable via insurance and they are the client’s responsibility.
Pam Moore PMHNP LLC does not except responsibility for referring clients to other providers or continuing to provide prescriptions for medications for clients whose services have been terminated.
I have read, understand, and agree to the above policies. I have discussed these policies with Pam Moore or her representative as I desire and all questions are answered to my satisfaction.
I authorize Pam Moore or her representative to release to my insurance company any information acquired in the course of my therapy, including information and records obtained from other sources, including but not restricted to relatives, the client, government entities and other providers.
I understand that my insurance coverage is a relationship between me and my insurance company and that I agree to accept financial responsibility for payment of charges incurred with Pam Moore PMHNP LLC. I understand that a re-billing fee/financial charge that complies with Oregon State Law will be applied to any overdue balance and, in the event of non-payment, I will bear the cost of collection and/or court costs and reasonable legal fees should they occur.
Consent to Treatment and Fee: I hereby agree to full responsibility for all expenses incurred by or on account of the client as printed below and signed by their legal representative. I hereby assign Pam Moore PMHNP LLC and that entity’s representatives to seek reimbursement by my insurance company or other financially responsible party for the expenses incurred as a result of receiving services from Pam Moore PMHNP LLC. I have read and understand the Notice of Privacy Practices and this Contract, Office hours, Scheduling Procedure and Financial Agreement; Limitation of Confidentiality when Providing Services to Couples, Acquaintances, or Family; and the Consent to Engage in Spiritual Base Psychotherapy. I agree to provide within two weeks of starting sessions with Pam Moore PMHNP LLC a completed Biopsychosocial History form. I understand that these forms are all available for review on-line at http://www.pmoore.carepaths.com. If conjoint (couple or family members) all adults need to sign this contract because of confidentiality and my rights, even though one person is the identified and paying client. Fees listed below are not guaranteed by insurance.
The following charges may be changed with notice:
Minimum fee—cash pay only for initial Interview = $300
Minimum fee—cash pay only for subsequent session = $200
Client Paperwork aside from normal assessments and prescriptions—including disability and pre-authorizations documentation is billed at $50 for each 15 minutes.
Your Copay / coinsurance= _________________ (The amount varies depending on insurance provider. Ranges from $0 -$125 per session. Call your insurance to confirm these charges.)
Late Cancellation/No Show = $200 (Waived if 24-hour notice of cancellation is given by client before the appointment)
Fee for Bounced Check; declined credit card; & Mailing prescriptions = $30
Client Printed Name ____________________________________
Client Signature____________________________________ Date _____________
P. Moore’s signature _______________________________________________
Other parties present and/or responsible parties:
Printed name and signature __________________________________________ Date ______________