Rine Medical Solutions LLC recognizes that seeking help from a mental health professional may not be easy. However, we hope that with our help, you will be able to understand your situation and feelings and move toward resolving your difficulties.

1. Treatment Agreement

I understand I have the right to ask questions throughout treatment and request an outside consultation. I also understand that my provider may provide me with additional information about specific treatment issues and treatment methods on an as-needed basis during treatment and that I have the right to consent to or refuse such treatment. I understand I can expect regular treatment reviews to determine whether treatment goals are being met. I agree to be actively involved in the treatment and the review process. No promises have been made regarding the result of this treatment or any procedures utilized within it. I further understand that I may stop treatment at any time but agree to discuss this decision first with my provider.

2. Appointment Policy

As a responsible patient, you play a key role in managing your appointments effectively. Please ensure to make and cancel appointments by calling (443) 961-1043, Monday through Friday between 9:00 am and 5:00 pm. To avoid a missed appointment charge, please cancel or reschedule at least 24 hours in advance. In case of an emergency, please call 911 or go to your nearest hospital emergency room. Local area clients can contact Baltimore Crisis Response at (410) 433-5175, Montgomery Crisis Center at (240) 777- 4000, or the National Suicide Prevention Lifeline at 1-800-273-8255. Please note that a $110.00 fee will be charged for appointments broken or canceled without a 24-hour notice.

3. Communication

By accepting these terms, you consent for Rine Medical Solutions LLC to communicate with you by mail, e-mail, and phone. However, we respect your privacy and understand that you may wish to opt out of any form of communication. Please notify Rine Medical Solutions LLC if you wish to do so. For non-urgent matters, please allow at least 24 business hours for a response. Messages left late in the day, on weekends, or on holidays may not be returned until the next business day. If you or someone close to you is in immediate danger, please call 9-1-1 or proceed to the nearest emergency room.

4. Medication Management

A thorough review of your current complaints and background will be conducted at your initial visit. You will be offered a preliminary impression by the end of the initial visit, and your treatment options will be discussed. Sometimes, psychotherapy alone will suffice. Often, however, a combination of psychotherapy and medical management is optional. Medications may be indicated when your mental symptoms are not responsive to psychotherapy alone. When a mental illness markedly impacts your ability to work, maintain interpersonal relationships, or adequately care for your basic needs, medication may offer much-needed relief. If it is agreed that medications are indicated, all available options to treat your current condition will be discussed with you. You will learn how the medication works, its dosage and frequency, its expected benefits, possible side effects, drug interactions, and any withdrawal effects you may experience if you stop taking the medication abruptly. By the end of the discussion, you will have all the information you need to decide which medication is right for you. You may already be receiving psychotherapy from another therapist and are referred to Rine Medical Solutions LLC for medication management. In this case, a solid effort must be made to coordinate care with your therapist (with your consent). Communication between mental health professionals is critical to providing adequate care. Not everyone is a good candidate for medication therapy. Such therapy requires strict adherence to dosage and frequency, close follow-up, and sometimes regular blood tests. I understand that it is my responsibility to inform my provider if I am on street drugs.

5. Laboratory Studies

My provider will request mandatory laboratory studies on my initial visit to recommend appropriate care.

6. Discharge Policy

I am aware that I will be terminated from receiving services from Rine Medical Solutions LLC if I fail to comply with orders, such as lab studies and providing records from previous providers, or if I fail to call or email the office and participate in my treatment for 90 days. Additionally, I will be required to provide records from previous providers and demonstrate a lack of interest in returning. I may be terminated from services if I neglect to sign the release of information or comply with my provider's request for records. You are entitled to terminate services at any time. I consent to receiving email notifications regarding my discharge from service.

7. No Show/Reschedule Policy

I understand that if I am a no-show for my appointment and do not call to reschedule within 14 days, I will be discharged from receiving services from Rine Medical Solutions LLC. I agree to be notified by e-mail. I understand that three consecutive no-shows are a discharge. I understand that two consecutive reschedules are considered one no-show.

8. Financial Terms

I understand that any portion of my medical bills not covered by insurance will be billed to me at the address I have provided. If you have insurance, you are responsible for providing the information needed to bill for services. I will bill your insurance company directly via electronic means on your behalf. If a check is mailed to you to cover your balance due, you are responsible for paying me that amount at our next appointment. If the insurance overpays me, I will credit it to your account or refund it if you prefer. Rine Medical Solutions LLC will submit the claims on the client's behalf. However, the client must understand that insurance plans require a diagnosis before filing a claim. This diagnosis will be discussed with the client during the session and kept in the client's clinical record.

I agree to allow Rine Medical Solutions LLC to charge my credit card on file the day services are rendered. I am responsible for having an active credit card on file for any past rendered services or for appointments broken or canceled without 24-hour advance notice. If my account has an outstanding balance, I understand that it must be satisfied before the next appointment.

9. Medication Refill Policy

I understand I must contact my provider seven days before a refill.

10. Social Media Policy

Providers cannot become "friends" with clients via social media, including, but not limited to, Facebook, Twitter (X), and Instagram. The ethical guidelines of the profession require therapists to avoid "dual relationships" with clients to protect the therapeutic relationship. To provide you with the best care possible, we shall focus on the relationship that is built in the confines of the therapeutic environment.

11. Telemental Health Terms

I comprehend that telemental health provides clinical health care services between a practitioner and a client in two locations through technology-assisted media or other electronic means. It is my understanding that technical difficulties may arise during a telemental health session, which could lead to service interruptions.

I am aware that the privacy laws that safeguard the confidentiality of my protected health information also apply to telemental health, unless an exception to privacy is established (e.g., mandatory reporting of child, elder, or vulnerable adult abuse; danger to self or others; I raise mental/emotional health as an issue in a legal proceeding).

I am aware that telehealth may entail the electronic transmission of my personal medical information to other medical professionals who may be situated in different regions, including out of state. I am aware that elemental health is associated with risks, benefits, and consequences, such as the restricted capacity to respond to emergencies, disruption of transmission due to technology malfunctions, and interruption and violations of confidentiality by unauthorized individuals.

I am aware that telemental health services may not be suitable for me if I am actively experiencing psychotic symptoms, undergoing a mental health crisis that cannot be resolved remotely, or having suicidal or homicidal intentions. In such cases, a higher level of care may be necessary.

12. ADHD Treatment Policy

Rine Medical Solutions LLC is cautious when it comes to treating adults with ADHD. Your acceptance of these terms shows that you understand that your provider may require the following documentation before initiating treatment:

• Prior records of ADHD treatment
• Neuropsychological evaluation results
• Medical Clearance
• Laboratory studies
• EKG reports
• Evidence of present or prior psychotherapy

Based on your psychiatric evaluation, your providers will collaborate with you to establish an individualized treatment plan.

13. Controlled Substances Policy

There is no evidence supporting the long-term use of Benzodiazepines. As such, Benzodiazepines are not intended for long-term use (longer than two weeks). Rine Medical Solutions LLC providers use evidence-based practice in their clinical decisions to provide quality care. Rine Medical Solutions LLC is a Benzodiazepines and other Controlled Substances Facility.

14. Form Completion Policy

Rine Medical Solutions LLC understands the value of patient-provider relationships. Establishing such a relationship takes time. Patients must have an established patient-provider relationship to complete forms. Thus, patients must be seen for over six (6) months, and the visits must be consecutive before completing any forms.

15. Treatment of Minors

Rine Medical Solutions LLC takes pride in caring for minors. Prior to providers treating minors, appropriate documentation demonstrating proof of who the parent/legal guardian is and a picture ID of the parent/legal guardian must be presented prior to the day of the appointment. The parent/Guardian must accompany the minor on the day of the appointment.

16. Release of Information

Rine Medical Solutions LLC recognizes the importance of collaboration between all providers involved in caring for patients. Patients will be requested to complete the release of information, which can be done prior to or on the day of the appointment.

17. Health Information Exchange

We have chosen to participate in the Chesapeake Regional ("CRISP"), a regional health information exchange ("HIES"} serving Maryland. CRISP is also affiliated with and shares data with other HIEs, including those in Alaska, Connecticut, D.C., Maryland, and West Virginia. As permitted by law, your health information will be shared with this exchange to provide faster access and better care coordination and assist providers and public health officials make more informed decisions. You may "opt-out" and restrict access to your health information available through CRISP by calling 1-877-952-7477 or completing and submitting an Opt-Out form to CRISP by mail, fax, or through their website at www.crisphealth.org. Public health reporting and Controlled Dangerous Substances information, as part of the Maryland Prescription Drug Monitoring Program (PDMP), will remain available to providers.