H Berryman Edwards, MD, FAPA |
|
H BERRYMAN EDWARDS, MD ___________________ Re:__________________ The above patient has requested that I manage his/her psychiatric medications while concurrently seeing you for psychotherapy. This agreement will help facilitate the treatment by clarifying our respective roles and modes of communication and ensuring that the patient understands them. Since you will be in more frequent contact with the patient, it is my understanding that you (or a psychotherapist covering for you) will be available at all times to the patient for emergency intervention. You will inform the patient that he/she is to contact you initially in any crisis or situation where hospitalization or some other urgent, non-medication-related care may be necessary. Of course, you may contact me as needed in such emergencies. The patient, however, will initially contact me only in the case of emergencies involving medication side effects or in the event that he/she is unable to reach you (or a psychotherapist covering for you). Moreover, since good communication between us is important for the success of the patient's treatment, we must agree to return each other's phone calls promptly, and to inform each other in a timely manner if the patient fails to keep appointments or otherwise fails to comply with treatment recommendations. In the event that the patient terminates with either of us, that provider shall promptly advise the patient to make an appointment with the other provider in order to review his/her overall treatment plan. The involvement of available family members in treatment is often helpful. I will be available for family sessions involving the patient, so long as you agree with the efficacy of such sessions but do not wish to hold them yourself. This treatment relationship is collaborative. We will ensure that the patient understands that there is no supervisory or agency relationship between us. Each of us is free to accept or reject the advice or recommendations made by the other. Each of us will bill the patient for services separately. The continuation of this treatment relationship is predicated on each of us fulfilling the terms of this agreement. Any modification of this relationship must be agreed to by each of us in order for it to be effective. Please indicate your agreement by signing below. Keep one copy for yourself, give one to the patient and return one to me. Thank you. Sincerely, H. Berryman Edwards, M.D.
I have read this agreement and understand and assent to its terms. ________________________________ (Psychotherapist Signature & Date) I have read and understand this agreement. ________________________________ (Patient Signature & Date) |
|
hbedwardsmd.com
|