ANNOUNCEMENTS at Chelmsford & Dracut Pediatrics

Patients are still required to wear a mask if they:

• Financial Obligation: Failure to meet financial obligations to Chelmsford Pediatrics, LLC and Dracut Pediatrics, regarding care provided or to cooperate with payment processes consistent with the practices payment policies.
• Clinic: Doctor of Medicine, Nurse Practitioner, Nurse & Lab
• Attendance, No Shows, & Canceled Appointments: Consistent or repeated failure to keep appointments without good cause and/or without notice of intent to cancel appointments. Termination of the relationship may occur with the goal of assuring appropriate continuity of care for the patient. When a patient cancels appointments on a repetitive basis without cause or enough notice, quality and continuity of care are adversely impacted, office schedules are disrupted, and it impedes other patients’ appointments. In order to decrease the incidence of such cases, a no-show fee will be applied to the patients account.
• No Show – A “no show” is considered by not attending a scheduled appointment without alerting the office. Patients may be responsible for $35.00 for each “no show.” Considerations will be given for emergency situations.

• Behavioral Health: Licensed Mental Health Counselor (LMHC) or Licensed Applied Behavior Analysis (LABA)
• Attendance, No Show, & Canceled Appointments: Any patient missing three consecutive scheduled appointments without communication will be discharged from mental health treatment. The patient is not discharged from clinic or the practice but will be discharged from behavioral health services. Considerations will be given for patients to be put on a waitlist.
• Late Cancellation – Patients may be responsible for $35.00 for each appointment not canceled within a 24-hour (about 1 day) timeframe. Considerations will be given for emergency situations.
• No Show – A “no show” is considered by not attending a scheduled appointment without alerting the office or therapist to cancel it. Patients may be responsible for $50.00 for each “no show.” Considerations will be given for emergency situations.

• Age Out: When a patient reaches the age of 26 they will no longer be eligible to have a pediatric doctor as their primary care physician according to the American Academy of Pediatrics. Providers will work with young adult patients ages 21-22 years old to start to plan their transition to an appropriate adult medicine provider.

Effective: 7/31/2024

Consent for Treatment:

I hereby consent to the behavioral health treatment provided by Chelmsford Pediatrics LLC. I authorize the mental health care services deemed necessary to address the needs of myself and my child[ren] including but not limited to, individual therapy, group therapy, and crisis intervention.

I agree to participate in a comprehensive intake assessment when beginning behavioral health treatment with Chelmsford Pediatrics LLC. I agree to provide accurate and complete information surrounding mental health symptoms and challenges including medication and hospitalizations.

Confidentiality:

I understand that information about the client, including session notes, will be kept confidential. I understand that records and information about the patient’s mental health treatment will not be released without consent and a signed release of information form.

I understand there are limits of confidentiality to protect the patient and others.

Limits of Confidentiality:

I understand that therapists are mandated reporters meaning that they are legally required to report certain information to authorities:

• Learned or suspected abuse or neglect.
• If a patient is under 18 and there is reported/suspected abuse, the therapist must notify child protective services (DCF).
• If a vulnerable or dependent adult reports abuse or abuse is suspected, therapists are required to report to the Disabled Persons Protection Commission (DPPC).
• Threats to cause harm to another person.
• Threats to harm themself including planned suicide attempts and/or recent self-injurious behavior.

Consent to Electronic Communications:

I consent to receive voicemails/emails regarding upcoming appointments and scheduling needs.

• I consent to receive Teletherapy services and understand that telehealth services involve the communication of my mental health information in an electronic or technology-assisted format. I understand that there are potential risks associated with the use of telehealth including but not limited to:
• Disruption of transmission by technology failures
• Interruption and/or breaches of confidentiality by unauthorized persons
• Limited ability to respond to emergencies

I understand that the limits of confidentiality also apply to Teletherapy services (i.e., mandatory reporting of child, elder, or vulnerable adult abuse, danger to self-and/or others.) By agreeing to receive Teletherapy services, I agree to attend video sessions in a safe and confidential location within the state of Massachusetts.

Attendance, No Show, and Late Cancellation Policies:

I understand that by signing this form I am responsible for attending scheduled appointments and maintaining consistent engagement with mental health services. Any patient missing three consecutive scheduled appointments without communication will be discharged from mental

health treatment.

• Late Cancellation – Patients may be responsible for $35.00 for each appointment not canceled within a 24-hour (about 1 day) timeframe. Considerations will be given for emergency situations.
• No Show – A “no show” is considered by not attending scheduled appointment without alerting the office or therapist to cancel it. Patients may be responsible for $50.00 for each “no show.” Considerations will be given for emergency situations.

Patient Code of Conduct:

Chelmsford Pediatrics is committed to providing high quality medical and mental health care. We strive to provide a safe, caring, and inclusive environment for both patients and care providers.

I understand that services may be terminated if any of the following occur:

• Offensive comments about others’ race, accent, religion, gender, sexual orientation, or other personal traits
• Refusal to see a clinician or other staff member based on these personal traits
• Physical or verbal threats and assaults
• Sexual or vulgar words or actions
• Disrupting another patient’s care or experience