Many people have not had experience with psychiatry services. I have written this to familiarize
you with psychiatric practice and to facilitate a good working relationship between you and I.
Below you will find policies that directly affect your care.
Appointment Scheduling
Please schedule appointments that you can keep unless there is a genuine emergency. I am
likely prescribing you medications, and cannot safely do so without seeing you in person. This
means you must keep your appointments to get your medications refilled. If a situation arises in
which you cannot keep your appointment and you will run out of medications because of this, I
will call in a MAXIMUM of two weeks supply of your medication to the pharmacy of your choice,
and any further refills will not be given until you are seen by me in person.
If you are not going to be able to keep an appointment, you must cancel with 48 hours notice,
or you will be charged a fee of $50.00.
Please keep in mind that if you cancel an appointment, another appointment may not be
available for a week or more. It is not typically possible to reschedule you for a different time
the same day.
If you cancel your appointment with less than 48 hours notice or do not attend your scheduled
appointment without advance notice 2 times, (unless a true emergency was the reason), I
reserve the right to discontinue your treatment.
I unfortunately cannot conduct appointments over the telephone.
If you are unable to schedule a follow up visit at the time of your in-person visit, you are
responsible for calling or e-mailing me to secure an appointment at a later time. I recommend
doing this at least 2 weeks in advance. I will not be able to call and remind you to reschedule.
Medications
If you require a refill of a medication, you must allow 2 business days to call in your refill.
Please be mindful of how much medication you have remaining.
When you need a refill, you may call or e-mail me to request one. Please provide the following
information: Your name, your date of birth, the name of your medication, the dose of your
medication, the number of times you take your medication per day, and the name and phone
number of the pharmacy at which you fill your prescriptions.
If you have questions or concerns regarding your medication, side effects, or symptoms, you are
encouraged to call or e-mail me. I make an effort to answer questions in a timely manner, but
please understand that a response can at times take up to 48 hours.
I can only provide a 30-day supply for any schedule II medications (e.g. stimulants).
Medications (continued)
If your insurance company requires a prior authorization for a medication (these are commonly
needed for stimulants, brand name medications for which generic versions are available, high
quantities of any medication, and for other reasons) the pharmacy usually will let me know,
unless the pharmacy tells you otherwise. In these cases, please allow up to 3 business days for
me to complete the paperwork and/or phone calls required by the insurance company. After
that point, the insurance company may also require several days for processing the information.
If you accidentally lose, misplace, or otherwise destroy your medication that is a controlled
substance (for example, benzodiazepines like Klonopin, Xanax, or Ativan or stimulants like
Adderall, Vyvanse, or Ritalin), you MAY be entitled to 1 early refill during the time of your
treatment. The safety of giving you an early refill of a controlled substance is assessed on a
case-by-case basis, for safety reasons.
Once we have begun treatment, you agree to not make any mental health medication changes
on your own without discussing it first with me, UNLESS you feel that taking a medication is
putting your life or health in danger or you are directed by another healthcare professional to
do so.
Timing
A full hour is needed for an initial evaluation. Sometimes though, more time than this is
required for me to complete a thorough evaluation. If I am unable to complete an evaluation
in one hour you will be asked to come back to complete the evaluation at the earliest available
time.
If you are 15 or more minutes late for any appointment, you will need to reschedule your
appointment.
Please allow up to 15 minutes in case I am running late as well, as sometimes emergencies do
arise. I make every effort to see you a the time you are scheduled, but at times it is necessary
for me to spend more time with patients who have complex or urgent concerns. If you are able
to wait, I will get to you as soon as possible. Otherwise I will reschedule your appointment as
soon as possible.
Administrative Work
If administrative work done outside of your appointment on your behalf requires 45 minutes or
more, your insurance company will be billed for this time (examples may be things like FMLA
paperwork, disability paperwork, research regarding your medication plan, creation of a
specialized medication taper). If your insurance company does not cover such services you will
be billed for this service at a rate of $75.00 per hour
Working with A Nurse Practitioner
As a Nurse Practitioner, I am required by PA state law to have a collaborating physician.
My collaborating physician is Tracey Jones, M.D. and I may discuss your treatment with
her as needed.
I must restrict my practice to mental health concerns. Therefore I am unable to
prescribe you medications that are used for anything other than mental health and I am
unable to perform physical exams.
If you are feeling suicidal or if you are otherwise feeling that your safety or life is in
danger, please go directly to the nearest emergency room, crisis response center, or dial
911.
If you need to call me multiple times per week, a higher level of care may be needed.
You may be recommended to seek other types of treatment (e.g. an intensive
outpatient program, partial hospitalization, or in-patient hospitalization). Alternatively,
you may be billed for this time at a rate of $125.00 per hour if it totals more than 15
minutes per week.
By signing here, you are acknowledging that you have read, understood and agreed to the
information in this document. For any clients under the age of 18, we request a signature of
both the legal guardian and the client.
__________________________________________________
__________________________
Signature/Printed Name
Date
__________________________________________________ ___________________________
Legal Guardian Signature/Printed Name
Date
__________________________________________________
__________________________
Elizabeth Milburn, MSN, CRNP
Date
By signing here, Elizabeth Milburn, CRNP is stating that she has given the above client the
opportunity to ask questions regarding the above policies and the client verbalized
understanding of all of the above policies.