~Office Policies~
Carol R Stampfer, PMHNP, FNP
833 SW 11th Ste.620 Portland, Oregon 97205 phone: 503-244-7739
This statement contains information regarding my office policies. Please read them and if you have any questions discuss them with me when we start our first visit. Your Initials at the bottom of the first sheet and your signature on the second sheet signifies that you have read, understand and agree to abide by these policies and that you have received a copy of the policies for yourself.
Appointments and Cancellations: After our first visit your appointments will be 50 minutes or 20 minutes long. Your appointment time is held exclusively for you. Please arrive on time so we can make the best use of your time. If you are unable to keep an appointment, please give me 48 hours of advanced notice. Advanced notice of less than 24 hours will be charged for the time as though you attended. Please note that insurance companies will not cover this charge and you will be responsible for covering this fee in full. I will charge the credit card number you have provided if this should occur. To cancel or make an appointment please call me at 503-244-7739.
Emergencies: In case of an urgent matter, you may reach me between appointments through my voicemail.
503-244-7739. If it is urgent please call and leave three separate messages. I check messages frequently. If you need immediate support for a psychiatric emergency you may contact the Crisis Line at 503-988-4888 or you may choose to call 911.
Fees: The fees for my professional services are $250.00 for an intake visit. This includes my 1) formal psychiatric evaluation, 2) communication with your Primary Care Provider if desired, 3) Request and review of your previous health records if desired, 4) setting up your file and working on the paperwork for insurance purposes if appropriate. After that visit my charges will be $150.00 for 50-minute sessions and $100.00 for 20-minute sessions. Phone calls that go over 10 minutes will be charged at a 150.00/hr rate. Most insurance companies will not pay for these calls.
Insurance: I will provide you with information to verify your expenses in receiving care from me. You can request coverage from your insurance company however I cannot guarantee that they will reimburse you. You will be responsible for the visit cost if they do not cover the service. Please check with your insurance company regarding the amount they will be willing to cover. My billing service is
In Its Place and the person you would talk to about billing questions is Amber Flores. Her number is: 503-914-5229. Please direct billing questions to her. There will be a rebilling charge of $25.00 if no payment on account has been made within 60 days after you have received the bill.
Office Arrangements: I share this suite of offices with other mental health practitioners. Each of us is in independent practice. We have no responsibility for each other’s businesses or patients. I manage my refill requests via fax or online. Please ask your pharmacy to call me at 503-244-7739 if you have not received your medications as you may have expected.
Confidentiality and Release of Information: Your participation in treatment and all information about you is confidential and will not be disclosed to anyone without your written consent. The only exceptions are: 1) Cases of suspected abuse or neglect of a child or elder, 2) Cases where I believe the client presents a clear and imminent danger to him/herself or to another person, 3) Cases where a court subpoenas me to testify or subpoenas my records, 4) Cases where an insurance company is helping to pay the fee and requires information about diagnosis and/or reports about treatment. If you are over 15 years of age you are granted the same confidentiality as an adult. However, there will be a need for me to talk with the financially responsible parties from time to time.
Your Record: Your record will be kept in my possession for the length of time required by law. You will need to sign a release and pay a copy fee in order for it to be sent outside of my offices. If I do not see you in my office or hear from you on the phone for greater than three months I may choose to close your file and we can consider our therapeutic relationship to have come to an end.
HIPPA Notice of Policies and Practices: I am committed to preserving the privacy of your personal health information. Additionally, I am required by Federal law (Health Insurance Portability and Accountability Act, Known as HIPPA) and by State law to protect the privacy of your personal information and to offer you a Notice that describes (a) how clinical information about you may be used and disclosed and (b) how you can get access to this information. Please ask for a copy of the HIPPA Notice of Policies and Practices should you wish to have a complete copy for your records.
Your signature below indicates that you have read this agreement and agree to all its terms. Your signature also serves as an acknowledgment that you have received the HIPPA Notice of Policies and Practices described above.
___________________________________________ _____________
Signature (client) Date
Please print your name:__________________________________________
___________________________________________ _____________
Signature (support person) Date
Please print your name:__________________________________________
If you do not show for an appointment or you cancel without 24 hour prior notice I will charge for the lost time. I reserve the right to bill this credit card for the amount of time
appointment would have taken. You may arrange for a phone appointment during the same time if needed.
Please sign that I may charge your credit card here: _____________________________
And put your credit card information below:
Name on the card:______________________________________________________
VISA/MasterCard number:
_____________________________________________________________________
Exp. Date: _____/______ Zip Code: 3 digit code_____