Eastern Shore Psychological Services - Eastern Shore of Maryland

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:: Informed Consent ::

Informed consent means that the services you are agreeing to, have been explained to you.

Therapy and Psychiatric Rehabilitation Services: Therapy is a process of understanding problems, gaining insight into their origin, expressing feelings, learning new skills, and planning for a happier, more fulfilling future. Psychiatric Rehabilitation Program (PRP) services help you with the practical, day-to-day issues related to your problems.

Research: Any research conducted by ESPS requires a separate consent form for participation. A client / parent / guardian may decline participation in any such research without pressure, coercion, or denial of services.

:: Clients' Rights ::

* You have the right to receive appropriate services in the least restrictive setting.

* You have the right to humane treatment.

* You have the right to be protected from harm and to be free from mental, physical and sexual abuse.

* You have the right to an individualized treatment or rehabilitation plan and to receive services as stated in that plan.

* You have the right to participate, in a manner appropriate to your condition, in the development and periodic review of your treatment or rehabilitation plan.

* You have the right to be told in appropriate terms and language of:
-The content and objectives of treatment or rehabilitation
-The nature and significant possible negative effects of treatment or rehabilitation

* You have the right to know the name, title and role of the staff members who are directly responsible for carrying out your treatment or rehabilitation, and when appropriate, other treatment services or providers of mental health services. You have the right to have access to your records. In the event that your physician believes that it would be harmful to you to read the entire record, this may be in the form of a written summary of your record. You also have the right, with written permission, for your attorney to have access to your records.

* You have the right to refuse medication.

* You have the right to refuse to participate in physically intrusive research.

* You have the right, prior to admission, to an explanation in terms and language that you can understand of admission and discharge policies.

* You have the right, prior to admission, to an explanation in terms and language that you can understand of the charges and fees that you will be required to pay.

* You have the right to an after care plan.

* You have the right to file a grievance if you are not satisfied with the treatment or rehabilitation that you receive.

:: Confidentiality ::

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Confidentiality refers to the rules that protect your privacy with respect to information about you and your family. It refers to medical information, mental health information, educational information or any information gathered about you by an agency or service. This means that ESPS may not release or obtain information about you without your written permission (release of information form).

There are some exceptions to these rules that have to do with safety.

* If we get information that leads us to suspect that a child is being abused we are required by law to report it.

* If we receive information that a person intends to harm him or herself we must take action to protect them.

* If we get information that you or someone in your family is planning to harm another person, we have a duty to warn that person.

Also information may be released if subpoenaed by the court, in the event there is a child abuse investigation or to obtain payment from your insurance company.

Confidentiality & Children

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* Confidentiality for children is more limited because communication with parents is important.

* Information to other agencies requires a parent or guardian’s written permission.

* We will attempt to allow children privacy and confidentiality when possible and appropriate.

* We encourage open communication between parents and children as part of the therapeutic process.

When is information about my case shared?

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* Therapists may discuss cases with other members of our treatment team. This is to provide supervision to each therapist and assure that you receive the highest quality service.

* Disclosure can be made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation.

* If information is to be shared with another agency in order to coordinate services, this will be discussed with you and you will be asked to sign a release.

* Certain information may be released to your insurance company to obtain payment.

:: Grievances ::

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If you feel these rights have been violated or have other concerns or complaints about the services you receive here:

* Speak with or write to your primary therapist, case manager or other staff member. They should respond within five days. If they do not or the problem is not resolved or you do not feel it is appropriate to speak to any of these individuals then...

* Speak or write to the Program Director, see page 12 for contact information. If you do not feel your concerns are addressed or you do not feel it is appropriate to speak to them then...

* Speak or write to the Administrative Director, Sarah Hooper or the Clinical Director, Lynn Gavigan at Eastern Shore Psychological Services: 2336 Goddard Parkway, Salisbury MD 21801. Phone: 410-334-6961. You will get a response within three days. If you do not or you do not feel your concerns are addressed or you do not feel it is appropriate to speak to them then...

* Contact the Executive Director - Dr. Kathy Seifert at Eastern Shore Psychological Services (address above), 410-334-6961. The Executive Director will respond within five days.

* If you still feel that your concerns are not addressed contact:

Wicomico County Core Service Agency,
108 East Main Street, Salisbury MD, 21801.
Phone: 410-543-6981

Mid-shore Mental Health Services
8221 Teal Drive Suite 203
Easton MD 21601
410-770-4801

Somerset County Core Service Agency
7920 Crisfield Highway
Westover MD 21871
443-523-1810

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* All allegations of client abuse by staff members must be reported to the local law enforcement agency or to the program director who must report them to the local law enforcement agency.

:: Fee Structure ::

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* ESPS accepts many insurance companies as well as Medicaid (paid through MAPS-MD ). Your coverage may require that you pay a co-pay. Co-pay amounts quoted to you by ESPS Staff are estimates based on available information from your insurance company. Actual Co-pay amounts may be higher or lower. We expect payment at each session. We are flexible and will work out payment plans if necessary. Please see the Office Manager.

* We have an agreement with MAPS-MD and a number of other insurance companies to accept their rate for services. In many cases those rates are different than our regular fees. We also have a sliding fee scale based on annual income and family size, for those clients who experience difficulty with payment and who receive no other coverage.

* If your bill is not paid in a reasonable amount of time it may be sent to collection and certain information may be released in order to collect the bill.

* If we are called to court on your behalf you will be billed an hourly fee appropriate to the clinician involved.

Treatment Fee Schedule

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Initial Evaluation

* Therapist $225

* Psychiatrist $250

* Psychologist $250

Individual 45—60 Min.

* Therapist $125

* Psychologist $150

Individual 20-30 Min

* Therapist $70

* Psychologist $100

* Psychiatrist $125

Group

* Adult $60

* C & A $60

Medication Visit $70

Court Appearance (per hour)

* Psychiatrist $175

* Psychologist $150

* Therapist $125

* Para-professional $90

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Psychiatric Rehabilitation (PRP) Fees

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Children— $396.75 per month (3 visit minimum)*

Adults—$707 per month (6 visit minimum)*

*Amounts are pro-rated if fewer than the minimum number of visits is completed

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If any ESPS staff member is called to Court on your behalf, you will be responsible for paying the hourly fees listed above plus travel expenses.

Unpaid Balances

ESPS understands that, even with the assistance of health insurance, payment for treatment may present a financial burden. Like any other company, ESPS expects payment at the time of service. However we are willing to work out payment plans or modified treatment schedules when necessary to help make fee payment easier while continuing to get the treatment that you need.

Unpaid balances grow quickly and then it is even more difficult to catch up. Beginning July 1, 2006 ESPS implemented a cap of $250 ($10 for “grey zone”) for unpaid balances. No more visits can be scheduled if you exceed the cap.

Please talk to your therapist or other staff member if you are having trouble paying fees or co-pays.

ESPS reserves the right to send unpaid balances to a collection agency to obtain payment.

:: Emergencies ::

If you or someone else is in immediate danger, please call 911

Salisbury emergency pager is 410-713-2481*.

Easton Emergency pager is 410-270-1033*.

LIFE CRISIS hot-line 410-749-HELP.

Peninsula Regional Medical Center 410-546-6400.

Shore Health Systems is 410-822-1000.

*Please use only for true emergencies

:: Discharge Policies ::

Discharge from ESPS Services will take place under the following circumstances:

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Collaborative Discharge

When MAPS-MD, in consultation with ESPS clinical staff, determine that the service is no longer medically necessary.

Individual’s Discontinuation of Services

When you decide you no longer wish to continue services we will offer information about alternative services and, with your permission and if appropriate, we will notify others involved with your case that you are being discharged.

ESPS Recommends Discontinuation of Services

Recommendation of Discontinuation of Services may be made because services are deemed inappropriate due to client actions, including non-compliance with treatment or rehabilitation plan. 30 days notice will be given to you except in the case of imminent danger.

Discharge Plan

In all cases ESPS will develop a discharge plan which will include the reason for admission, the reason for discharge , treatments provided, progress, prognosis , referrals and/or recommendations. When possible, this plan is developed in collaboration with you.