Terms and Conditions of Service

MASTER SERVICE AGREEMENT, INFORMED CONSENT & PRIVACY PRACTICES

Constructive Psychiatry (Insurance Division) | Stasis Behavioral Health, LLC (Self-Pay Division)

EFFECTIVE DATE: January 24, 2026 (Valid Until Replaced)

PREAMBLE: THE DUAL PRACTICE MODEL

This Agreement is entered into by and between the Patient (hereinafter "Patient," "You," or "Your") and the Practice Group operating as Constructive Psychiatry and Stasis Behavioral Health, LLC (collectively "The Practice," "We," "Us," or "Provider").

CRITICAL NOTICE: The Practice operates two distinct business entities.

1. Constructive Psychiatry: Accepts select insurance plans.

2. Stasis Behavioral Health, LLC: Strictly self-pay (concierge model).

3. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOUR FINANCIAL OBLIGATIONS DEPEND ENTIRELY ON WHICH ENTITY YOU ARE SCHEDULED WITH FOR EACH SPECIFIC APPOINTMENT.

I. SCOPE OF SERVICES & PROVIDER DEFINITIONS

A. THE CLINICAL TEAM

You acknowledge that care may be provided by a collaborative clinical team. You explicitly consent to evaluation and treatment by:

1. Psychiatric Mental Health Nurse Practitioners (PMHNP-BC): Advanced practice providers licensed to prescribe and treat autonomously in applicable states.

2. Psychotherapists (LCSW/LMFT/LPC): Licensed professionals providing counseling and behavioral therapies.

B. NOT AN EMERGENCY SERVICE (STRICT POLICY)

The Practice is strictly an outpatient clinic and is not equipped for crisis management.

1. No On-Call Duty: We do not offer 24-hour on-call availability. Providers do not check messages after business hours.

2. Mandatory Crisis Protocol: If You are in crisis, suicidal, homicidal, or experiencing a severe drug reaction, You agree to immediately call 911, call/text 988, or proceed to the nearest Emergency Room.

3. Release: You explicitly release The Practice from any liability for events occurring after-hours if You fail to utilize these emergency resources.

II. TELEHEALTH & LOCATION STRICT LIABILITY

A. LOCATION MANDATE

Licensure regulations strictly limit Providers to treating patients physically located in states where the Provider holds a license.

1. Warranty: You represent and warrant that You are physically located in a state where Your Provider is licensed at the time of every session.

2. Immediate Termination for Breach: If You attempt to conduct a session from an unlicensed jurisdiction (e.g., while on vacation in a different state), the session will be immediately terminated, and You will be liable for the full cancellation fee.

3. Indemnification: You agree to indemnify and hold harmless The Practice from any legal, administrative, or licensure sanctions (including legal fees) resulting from Your misrepresentation of Your physical location.

III. COMPREHENSIVE INFORMED CONSENT

A. PSYCHOTHERAPY RISKS & BOUNDARIES

1. Emotional Risk: Psychotherapy involves discussing painful aspects of Your life. You acknowledge this may temporarily increase feelings of sadness, guilt, anxiety, anger, or frustration before improvement occurs.

2. No Guarantees: The Practice makes no warranties regarding a "cure," specific symptom resolution, or the duration of treatment.

3. Forensic & Administrative Exclusion: We provide clinical treatment only. We do not perform custody evaluations, worker's compensation assessments, or forensic legal work. We do not write letters for Emotional Support Animals (ESA) or permanent disability unless explicitly agreed upon in a separate written agreement. You agree not to subpoena Your Provider for legal proceedings.

B. MEDICATION MANAGEMENT & "BLACK BOX" WARNINGS

1. General Risks: All psychiatric medications carry risks, including but not limited to: sedation, weight gain, metabolic changes, sexual dysfunction, and rare but serious reactions like Stevens-Johnson Syndrome or Serotonin Syndrome.

2. Duty to Read: You agree to read the FDA Patient Information Leaflet provided by your pharmacy for every medication prescribed. You agree to specifically ask Your Provider about "Black Box Warnings" associated with Your medication.

3. Pregnancy & Medical Changes: You agree to immediately inform Your Provider if You become pregnant, plan to become pregnant, or develop a new medical condition, as this significantly affects medication safety.

C. CONTROLLED SUBSTANCE POLICY (STRICT ENFORCEMENT)

If You are prescribed controlled substances (e.g., stimulants, benzodiazepines):

1. Lost/Stolen Medication: The Practice strictly requires a formal Police Report for any claim of lost or stolen controlled substances.

2. Replacement Discretion: WE DO NOT GUARANTEE REPLACEMENT. Even with a police report, the decision to send a replacement order is at the sole discretion of the Provider.

3. Pharmacy Discretion: You acknowledge that the final decision to fill a controlled substance rests with the Pharmacist. The Practice cannot force a pharmacy to fill a prescription if they deem it unsafe, too early, or suspicious.

4. PDMP Checks: You consent to The Practice querying state Prescription Drug Monitoring Programs (PDMP). Finding undisclosed prescriptions from other providers is a breach of this Agreement and grounds for immediate discharge.

D. TECHNOLOGY & ARTIFICIAL INTELLIGENCE (AI) CONSENT

1. Use of AI Tools: The Practice may utilize HIPAA-compliant Artificial Intelligence (AI) tools for administrative and documentation purposes, including but not limited to "AI Scribes" (software that listens to sessions to generate clinical notes) or intake automation.

2. Human Oversight: You acknowledge that while AI may assist in drafting documentation, all clinical decisions, diagnoses, and treatment plans are made solely by your human Provider. The AI does not practice medicine.

3. Electronic Communication Risks: You acknowledge that email, text messaging, and video conferencing (Telehealth) rely on technology that may be subject to failure or security breaches. While We use encrypted platforms, We cannot guarantee absolute security. You consent to the use of these technologies for Your care.

IV. FINANCIAL POLICY & FEE AGREEMENT

A. MISSED APPOINTMENTS & FEE SCHEDULE

1. Liquidated Damages: You acknowledge that a "No-Show" or late cancellation (less than 24 hours) causes a financial loss that is difficult to calculate.

2. The Fee: You agree to pay a Liquidated Damages Fee (not a penalty) for any missed appointment.

• Current Fee: As of the Effective Date, this fee is $85.00.

• Constructive Notice of Changes: This fee amount is subject to change based on economic factors. You agree that You are responsible for checking the current fee schedule at www.stasisbehavioralhealth.com or www.constructivepsychiatry.com prior to every appointment.

3. Ratification: You agree that Your act of scheduling or attending a new appointment constitutes Your acceptance and ratification of the fees posted on the website at that time.

B. GOOD FAITH ESTIMATE (SELF-PAY PATIENTS)

Under the federal No Surprises Act, if You are uninsured or strictly self-pay (Stasis Behavioral Health):

1. Right to Estimate: You have the right to receive a Good Faith Estimate (GFE) explaining how much your medical care will cost.

2. Upon Request: You may request a Good Faith Estimate before you schedule an appointment.

3. Provision: If You schedule an appointment at least three (3) business days in advance, We will provide this Estimate in writing. You may also request a GFE at any time during Your treatment.

C. PRIOR AUTHORIZATIONS (PA)

1. No Guarantee: Insurance companies may require a Prior Authorization (PA) for certain medications. The Practice will attempt to submit PAs as a courtesy, but we are not responsible for the outcome.

2. Financial Responsibility: If a PA is denied or if Your insurance drops coverage, You are solely responsible for the cash price of the medication or for consulting Your Provider to discuss generic alternatives. A PA denial is an insurance decision, not medical malpractice.

D. CREDIT CARD ON FILE

You authorize The Practice to keep a valid credit card on file and to automatically charge said card for:

1. Missed Appointment/Late Cancellation fees ($85.00 or current rate).

2. Copays, deductibles, and coinsurance (for Constructive Psychiatry).

3. Full session fees (for Stasis Behavioral Health).

V. NOTICE OF PRIVACY PRACTICES & DATA RIGHTS

A. USES AND DISCLOSURES OF HEALTH INFORMATION

By signing this Agreement, You consent to The Practice using and disclosing Your Protected Health Information (PHI) for the following purposes:

1. Treatment: We may use Your PHI to provide medical care and disclose it to other professionals involved in Your care (e.g., Your pharmacy or primary care physician).

2. Payment: We may use Your PHI to bill Your insurance (Constructive Psychiatry) or process credit card payments.

3. Healthcare Operations: We may use Your PHI for internal quality assessment, licensing, and business management.

B. YOUR RIGHTS REGARDING YOUR PHI

You have the following rights regarding Your health information:

1. Right to Inspect and Copy: You have the right to inspect and obtain a copy of Your medical record.

2. Right to Amend: If You feel Your medical information is incorrect, You may request an amendment in writing.

3. Right to Request Restrictions: You may request a restriction on how we use Your PHI, though We are not legally required to agree to all restrictions.

4. Right to a Complaint: If You believe Your privacy rights have been violated, You may file a complaint with The Practice or with the U.S. Department of Health and Human Services (OCR). We will not retaliate against You for filing a complaint.

C. CONSUMER HEALTH DATA (WA/NV/CO)

To ensure compliance with state Consumer Health Data laws (e.g., Washington My Health My Data Act), if we collect data outside the scope of HIPAA:

1. Explicit Consent: You strictly consent to the collection and use of Your Consumer Health Data for the purpose of providing services.

2. No Sale: We represent that we do not sell Your Consumer Health Data.

3. Withdrawal: You may withdraw this specific consent for non-HIPAA data at any time via written notice.

VI. TERMINATION OF CARE

A. RIGHT TO TERMINATE

The Practice reserves the right to terminate the provider-patient relationship for reasons including, but not limited to:

1. Legal Conflict: Any threat of legal action, filing of a lawsuit, or administrative complaint against The Practice or its Providers creates an immediate conflict of interest and an irretrievable breakdown of the therapeutic alliance, resulting in immediate termination.

2. Non-Payment: Failure to pay fees, copays, or insurance denials.

3. Non-Compliance: Failure to adhere to treatment recommendations or violation of the Controlled Substance Policy.

4. Abuse: Abusive, threatening, or harassing behavior toward staff or providers.

B. NOTICE & BRIDGE PRESCRIBING

In the event of termination, We will provide notice and, where clinically appropriate, a bridge prescription (for non-controlled substances) to allow You time to find a new provider.

Please Note: During this termination notice period, The Practice remains an outpatient clinic. We do not provide emergency services during the transition. You understand and agree to utilize 911 or the closest Emergency Room for any crisis at your expense.

VII. LIMITATION OF LIABILITY & DISPUTE RESOLUTION

A. LIMITATION OF LIABILITY

TO THE FULLEST EXTENT PERMITTED BY LAW, THE PRACTICE’S TOTAL LIABILITY FOR ANY CLAIM ARISING OUT OF THIS AGREEMENT SHALL BE LIMITED TO THE AMOUNT OF FEES PAID BY YOU IN THE SIX (6) MONTHS PRECEDING THE CLAIM. WE DISCLAIM ALL LIABILITY FOR DAMAGES ARISING FROM INSURANCE DENIALS, PHARMACY REFUSALS, OR THIRD-PARTY TECHNOLOGY FAILURES.

B. MANDATORY ARBITRATION & CLASS WAIVER

1. Arbitration: Any dispute arising out of Your care or this Agreement shall be resolved by Binding Arbitration administered by the American Arbitration Association (AAA). YOU WAIVE YOUR RIGHT TO A JURY TRIAL.

2. Class Action Waiver: You agree to bring claims only in Your individual capacity, not as a plaintiff or class member in any class or representative action.

C. GOVERNING LAW

This Agreement is governed by the laws of the State where the treating Provider is licensed and located at the time of service.

VIII. FINAL ACKNOWLEDGMENT & COMPREHENSIVE ACCEPTANCE

By clicking "I AGREE" or signing below, I explicitly acknowledge and certify that:

1. Entire Agreement: I have read this Master Service Agreement, Informed Consent, Notice of Privacy Practices, and Policy Manual (Sections I through VII) in its entirety. I fully understand its terms and agree to be bound by all provisions contained herein.

2. Financial Responsibility: I accept the $85.00 Liquidated Damages Fee for missed appointments. I understand that I am entitled to a Good Faith Estimate upon request if I am a self-pay patient.

3. Controlled Substances: I understand that Lost/Stolen Controlled Substances strictly require a Police Report and that replacement is never guaranteed.

4. AI & Technology: I consent to the use of Artificial Intelligence for documentation assistance and acknowledge the inherent risks of electronic communication.

5. Dispute Resolution: I voluntarily and knowingly consent to Binding Arbitration and Waive my Right to a Jury Trial as outlined in Section VII.

I HEREBY CERTIFY THAT I AM COMPETENT TO SIGN THIS AGREEMENT AND DO SO VOLUNTARILY.

BY ELECTRONICALLY SIGNING, I ACCEPT AND AGREE TO THE ENTIRE AGREEMENT.