MASTER SERVICE AGREEMENT, INFORMED CONSENT & PRACTICE POLICIES
Constructive Psychiatry (Insurance Division) | Stasis Behavioral Health (Self-Pay Division)

EFFECTIVE UNTIL FORMALLY UPDATED IN WRITING

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

 (collectively "The Practice," "We," "Us," or "Provider").

CRITICAL NOTICE: DUAL PRACTICE STRUCTURE

 The Practice operates two distinct business entities sharing a single administrative portal.

• Constructive Psychiatry:

•  Accepts select insurance plans.

• Stasis Behavioral Health:

•  Strictly self-pay (concierge model). 

• 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 & TELEHEALTH CONSENT

A. Nature of Services

 The Practice provides outpatient psychiatric evaluation, medication management, and psychotherapy. 

WE DO NOT PROVIDE EMERGENCY SERVICES.

 The Practice is not equipped for crisis management. If You are experiencing a medical or psychiatric emergency, are in crisis, or have thoughts of harming Yourself or others, You agree to immediately call 911, call/text 988, or proceed to the nearest Emergency Room.

B. Telehealth Informed Consent (Multi-State Compliance)

 You voluntarily consent to receive health care services via Telehealth (audio-video technology). You understand and agree that:

• Location Mandate:

•  You must be physically located in a state where Your Provider is currently licensed at the time of the session. You agree to disclose Your physical location immediately upon connection. If You are out-of-state, the session must be terminated legally.

• Privacy:

•  You are responsible for securing a private, confidential space. The Practice is not liable for breaches of privacy caused by Your environment (e.g., being in a public place or having others in the room).

• Technology Failure:

•  If technology fails, the Provider will attempt to reconnect. If a session cannot be completed, it may be rescheduled.

• Risk of Lost Cues:

•  Telehealth limits the Provider’s ability to observe physical cues (smell of alcohol, subtle tremors, etc.), which may impact diagnostic accuracy. You accept this inherent risk.

II. THE "HYBRID" FINANCIAL POLICY

A. Designation of Status

• Default Status:

•  Until You provide valid insurance information verified by 

• Constructive Psychiatry

• , You are considered a 

• Stasis Behavioral Health

•  (Self-Pay) patient.

• The "Switching" Protocol:

•  You have the right to switch between the Insurance Division and the Self-Pay Division. To effectuate a switch, You must:

  • Draft a written notice stating Your intent to switch (e.g., "I am switching to [Practice Name] effective [Date]").

  • Sign and save this notice as a 

  • PDF

  • Upload the PDF to the "Files" section of Your Patient Portal.

  • TIMING:

  •  This must be completed 

  • PRIOR

  •  to the start of the next scheduled appointment. Switches cannot be applied retroactively to past appointments.

B. Terms for Constructive Psychiatry (Insurance)

• Verification:

•  Verification of benefits is not a guarantee of payment.

• Financial Liability:

•  You are responsible for all Deductibles, Co-Pays, and Co-Insurance. If Your insurance denies the claim for 

• any

•  reason (including "Not Medically Necessary" or "Coverage Terminated"), You become immediately liable for the full standard rate of the service.

C. Terms for Stasis Behavioral Health (Self-Pay)

• Payment Due:

•  Full payment is collected at the time of service.

• INSURANCE WAIVER & COVENANT NOT TO SUE:

•  By choosing Stasis Behavioral Health, You explicitly acknowledge that You are voluntarily choosing a direct-pay model. You agree 

• NOT

•  to file claims with Your insurance carrier for reimbursement unless Your plan allows Out-of-Network submissions. The Practice will not file claims for Stasis appointments.

D. Medicare & Medicaid Disclaimer (Strict Compliance)

• Medicaid Waiver:

•  The Practice (both divisions) typically 

• DOES NOT participate in state Medicaid programs. By signing this Agreement, You represent and warrant that if You are a Medicaid beneficiary, You are voluntarily exercising Your right to seek care outside of the Medicaid network. 

• You agree to pay out-of-pocket and acknowledge that Medicaid cannot be billed for these services.

• Medicare Opt-Out:

•  If Your Provider has opted out of Medicare, You acknowledge that neither You nor the Practice may submit claims to Medicare and that you voluntarily agree to waive your right to Medicare benefits and to pay for services as a self pay patient.

E. Cancellation Policy (The "Flat Fee" Rule)

 Your appointment time is reserved exclusively for You.

• Requirement:

•  Cancellations must be made via the Portal at least 24 hours in advance.

• The Penalty:

•  If You "No-Show" or cancel with less than 24 hours' notice, You will be charged a FLAT FEE

  • Fee Calculation:

  •  This fee is set at a flat rate equivalent to the lowest-priced appointment type currently offered by the Practice.

  • Automatic Charge:

  •  You authorize the Practice to charge this fee to the credit card on file immediately upon the missed appointment. This fee is generally ineligible for insurance reimbursement.

III. INFORMED CONSENT FOR TREATMENT

A. Diagnosis and Treatment Plan

You have the right to be informed of Your diagnosis, the nature and purpose of proposed treatments, and the prognosis (expected outcome).

B. Consent for Medication Management

 If medications are prescribed, You acknowledge the following:

• No Guarantees:

•  Psychiatry is not an exact science. Response to medication is variable. There is no guarantee of symptom improvement or cure.

• Material Risks:

•  All medications carry risks. You acknowledge awareness of potential risks including, but not limited to:

  • Common:

  •  Nausea, headache, insomnia, weight gain/loss, sexual dysfunction.

  • Severe:

  •  Serotonin Syndrome, Stevens-Johnson Syndrome (rash), Cardiac arrhythmias, Metabolic Syndrome.

  • Tardive Dyskinesia:

  •  Involuntary movements associated with certain antipsychotics.

  • Black Box Warning (Suicidality):

  •  You are aware that antidepressants and other psychotropics may increase the risk of suicidal thinking and behavior in children, adolescents, and young adults (up to age 24). You agree to monitor for these changes and report them immediately.

• Right to Refuse:

•  You have the right to refuse medication or to stop taking it at any time. However, You understand that stopping certain medications abruptly can cause severe withdrawal (discontinuation syndrome) or relapse. 

• You agree to consult the Provider before stopping any medication.

C. Controlled Substances Policy (Strict Adherence)

 Regarding medications classified as Controlled Substances (e.g., Benzodiazepines, Stimulants):

• No Obligation:

•  The Provider is under no obligation to prescribe controlled substances, even if You were prescribed them by a previous doctor.

• Monitoring:

•  The Practice utilizes Prescription Drug Monitoring Programs (PDMP). We reserve the right to require Random Urine Drug Screens or Pill Counts at Your expense.

• Termination:

•  Creating duplicate prescriptions, obtaining controlled substances from multiple providers ("Doctor Shopping"), or early refill requests due to "lost" medications are grounds for immediate termination of care.

D. Use of Artificial Intelligence (AI)

 The Practice utilizes HIPAA-compliant Artificial Intelligence tools to assist in documentation (medical scribing) and clinical decision support.

• Human Oversight:

•  All AI-generated notes or recommendations are reviewed, verified, and finalized by Your human Provider. The Provider retains full responsibility for Your care.

• Consent:

•  By signing below, You consent to the processing of Your audio/voice data by these secure AI systems for the purpose of creating Your medical record.

IV. PRIVACY, COMMUNICATIONS & LIABILITY

A. Electronic Communications

• The Portal:

•  The Patient Portal is the only secure way to communicate clinical information.

• Email/Text Waiver:

•  Standard email and text messaging are not secure and can be intercepted. If You choose to contact Us via standard email/text, You acknowledge that You are waiving Your HIPAA privacy rights regarding that specific communication and accept the risk of exposure.

B. Termination of Provider-Patient Relationship

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

• Non-payment of fees.

• Non-compliance with the treatment plan.

• Verbal abuse, threats, or harassment of staff.

• Two or more "No-Shows" or Late Cancellations. Upon termination, You will be offered a referral period (usually 30 days) for emergency medication coverage only, to allow You to find a new provider.

C. LIMITATION OF LIABILITY & ARBITRATION

TO THE FULLEST EXTENT PERMITTED BY LAW:

• NO WARRANTIES:

•  THE PRACTICE MAKES NO REPRESENTATIONS OR WARRANTIES, EXPRESS OR IMPLIED, REGARDING THE OUTCOME OF YOUR TREATMENT.

• INDEMNIFICATION:

•  YOU AGREE TO INDEMNIFY AND HOLD HARMLESS THE PRACTICE, ITS OWNERS, AND PROVIDERS FROM ANY CLAIMS ARISING OUT OF YOUR BREACH OF THIS AGREEMENT, YOUR NEGLIGENCE, OR YOUR WITHHOLDING OF ACCURATE MEDICAL INFORMATION.

• DISPUTE RESOLUTION:

•  ANY DISPUTE ARISING OUT OF OR RELATED TO THIS AGREEMENT OR YOUR CARE SHALL BE RESOLVED BY BINDING ARBITRATION IN THE STATE WHERE THE SERVICES WERE RENDERED, RATHER THAN IN COURT. 

• YOU HEREBY WAIVE YOUR RIGHT TO A JURY TRIAL.

V. ACKNOWLEDGMENT AND SIGNATURE

By electronically signing below, I certify that:

• I have read this Agreement in its entirety.

• I am competent to consent to treatment.

• I understand the Dual Practice Model and the Protocol for Switching

• I understand and agree to the Financial Policy, including the Flat Fee Cancellation Policy

• I have been informed of the risks and benefits of treatment (Informed Consent) and the use of Telehealth.