Consent to Treatment

I authorize Shanthi Trettin, M.D., M.A. of Choice Psychiatric Healthcare, LLC (CPH) to provide therapy and medications as necessary and as agreed upon by me. I understand that it is the responsibility of Dr. Trettin to explain diagnostic tests and available treatment options, including the most common side effects, risks, and benefits. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and treatment.

I agree that it is my choice to use email to contact Dr. Trettin. I understand that email communication is a convenience and not appropriate for emergencies or time-sensitive issues. I am aware that CPH email communications are encrypted and password protected. It is, however, not possible to guarantee the privacy of email messages. Employers generally have the right to access any email received or sent by a person at work. I understand that, at the discretion of Dr. Trettin, my email communications may need to be replaced either by phone calls or office visits. I hold harmless CPH for information loss due to technical failures of equipment.

I understand that CPH utilizes a secure Zoom business account for virtual sessions. This account protects privacy, confidentiality, and personal health information. When I join CPH Zoom meetings, I consent to participate in sessions that comply with HIPAA regulations.

Coverage

• Minimum frequency of sessions is every four months to maintain safety and quality of care.

• Email is the preferred method of communication.

• For prescription requests, please contact Dr. Trettin directly (refill requests from pharmacies are often inaccurate, outdated, or duplicates of scripts already completed).

• Dr. Trettin does her best to respond to messages in a timely fashion.

• For issues that cannot wait for a response, or for true emergencies, please call 911 or go to your local Emergency Room.

• Dr. Trettin reserves the right to discharge patients from CPH at her discretion (e.g., because the patient needs a higher level of care or because of extensive noncompliance) and would then facilitate transition to new care.

Location

• Out of respect for neighborhood traffic and limited parking, patients are asked to drive slowly down Belmont Avenue (a one-way residential street), to try and arrive a few minutes prior to the scheduled appointment time, and to park in the driveway (not on the street).

• There are two parking spaces immediately in front of the garage; patients should park on either the right side or the left side so that each of two cars can easily get in and out.

• The office and waiting room are above the garage; patients should use the outdoor staircase that is to the right of the house (do not use the front door of the house).

• If there is an active infectious illness, please choose or shift to a virtual visit.

Payments

• Payment is due upon receipt of invoice via credit card or electronic bank account.

• Each invoice bills for the specific session or paperwork type and includes a processing fee ($10/session and $5/paperwork).

• Each patient is required to store a preferred credit card through the secure payment authorization form.

• CPH will charge the card on file if payment has not been made within one week of the appointment.

• Each patient is responsible for any bank fees related to declined credit cards or returned checks.

• CPH reserves the right to use a collection agency which may lead to additional fees.

• Dr. Trettin will not see patients for appointments if there is any outstanding balance.

• If a patient does not come or cancels within 24 hours of their scheduled appointment, 100% of the fee will be charged.

Ethics

Practice is HIPAA (Health Insurance Portability and Accountability Act) compliant. Confidentiality is maintained with the following exceptions:

• Communication with other health care providers (if the patient agrees).

• Interaction with family members or partner (if the patient agrees).

• If the patient is an immediate and significant danger to herself or to others.

• If Dr. Trettin learns of behaviors that may constitute legal child abuse or neglect.

• If the patient’s ability to drive becomes an obvious and serious concern, the state requires that this be reported.

• If Dr. Trettin is court-ordered by a judge to provide information about the treatment (every attempt would be made to preserve confidentiality).

• If a law enforcement official requires information to identify or locate a suspect, fugitive, material witness, or missing person.

Research / Drug Companies

Dr. Trettin maintains up-to-date knowledge through reading clinical literature that is peer-reviewed and non-industry biased (not funded by pharmaceutical companies).

I reviewed practice policies outlined above. I was given the opportunity to ask questions and my questions were answered.