DISCLOSURE & INFORMED CONSENT

Provider & Scope of Practice: Jeanette Houghtelling, DNP, PMHNP-BC, is a Psychiatric Mental Health Nurse Practitioner licensed in Montana as an APRN with full practice authority. She may evaluate, diagnose, order labs, prescribe medications (including controlled substances), provide psychotherapy within her scope, and manage individualized treatment plans.

Care Approach & Voluntary Choices: Next Steps Psychiatry & Psychotherapy provides trauma-informed, whole-person care incorporating medication, psychotherapy, and evidence-based lifestyle strategies (nutrition, movement, sleep, stress management, and social connection).

• Voluntary Participation: You have the right to decline medication or psychotherapy, request one without the other, seek a second opinion, or decline treatment altogether.

• Risks & Benefits: Benefits may include symptom reduction, improved mood, and better coping skills. Risks include emotional discomfort, medication side effects, or lack of improvement. No specific treatment results are guaranteed.

Appointments, Cancellations, & Late Policy

• Appointment Length & Late Arrivals:

  • Initial Intake: 75 min with your provider (scheduled for 90 minutes): Arriving more than 15 minutes late will result in cancellation and a late cancellation fee.

  • Follow-Up Medication Management: 20 minutes with your provider (scheduled for 30 minutes)

  • Psychotherapy Session: 50 minutes with your provider (scheduled for 60 minutes)

  • Arriving late to any session will reduce your total session time. Appointments may be rescheduled at the provider's discretion.

• Telehealth Eligibility: Face-to-face sessions are strongly preferred over telehealth sessions. However, if you are out of town, sick, or need additional support, telehealth appointments are available.

• Please Note: You must be in Montana for all telehealth appointments.

• Card on File: We must have a valid credit card on file to hold all appointments.

• Cancellation Notice & Fees: We must receive cancellations or rescheduling requests at least 48 hours in advance.

  • Initial Evaluations: $150 fee for no-shows or late cancellations.

  • Follow-up Appointments: $100 fee for 30-minute appointments, $150 fee for 60-minute appointments

  • Fees may be waived at the provider's discretion for documented illness or emergencies.

Fees & Billing

Please see our Financial Agreement for additional information regarding our billing and payment policies.

Our practice accepts a variety of health insurance plans, including, but not limited to: Allegiance, Medicare, Medicaid, Tricare, TriWest, Blue Cross/Blue Shield, First Choice Health, Mountain Health Coop, Optum, Pacific Source, GEHA, United Healthcare. Please note that you are responsible for contacting your insurance carrier to confirm coverage under your specific plan.

If you are uninsured or your specific plan is not accepted, payment is due in full at the time of service. If you wish to seek out-of-network reimbursement from your insurance company, please coordinate with our administrative team, and we will provide you with a superbill to submit to your carrier.

Evaluation & Management (E/M) Services

• CPT 90792 – Psychiatric Diagnostic Evaluation: $450.00

• CPT 99215 – Established Patient Office Visit (High Complexity): $350.00

• CPT 99214 – Established Patient Office Visit (Moderate Complexity): $275.00

• CPT 99213 – Established Patient Office Visit (Low/Moderate Complexity): $200.00

• CPT 99417 – Prolonged Outpatient E/M Service (Each additional 15 minutes): $75.00

Therapy & Assessment Add-on Codes

• CPT 90838 – Psychotherapy Add-on (60 minutes, with E/M service): $300.00

• CPT 90836 – Psychotherapy Add-on (45 minutes, with E/M service): $240.00

• CPT 90833 – Psychotherapy Add-on (30 minutes, with E/M service): $200.00

Private Pay Rates for Standard Appointments:

For patients who do not have insurance coverage, our Private Pay Rates are as follows:

• 90 Minute Appointment (Initial Intake): $250.00

• 60 Minute Appointment: $175.00

• 30 Minute Appointment: $150.00

Additional Fees:

• A $10.00 service charge applies to all returned checks.

• Medical records will be forwarded to providers, free of charge. If you are requesting records for your own personal use, a fee will apply. The final cost depends on the number of pages and extent of the records requested.

Medication Policies & Refills

Please see our Controlled Medication Agreement for additional information regarding our medication policies

• Refill Requests:

  • Patients are responsible for monitoring their medication supply and requesting refills before their medication runs out.

  • To request a refill, please select the "Medications" icon on the homepage of your portal account and select the "Refill" option for the medication you are looking to fill.

• Processing:

  • Medication refill requests are reviewed and processed during regular clinical hours, Monday through Thursday, excluding holidays. Please allow up to 7 business days for routine refill requests.

  • Patients are encouraged to request refills at least one week before their medication is expected to run out to allow adequate processing time and address any issues that may arise with the pharmacy, insurance company, or medication availability.

• Policies:

  • Certain medications may require an appointment, additional clinical assessment, laboratory testing, or review of prescription monitoring program data before we can authorize a refill. Refills are generally not provided after hours, on weekends, or during holidays.

  • Medication refill requests should not be considered urgent or emergency communications. If you experience a medication-related emergency, seek immediate medical attention, call 911, or call 988 as appropriate.

  • Take controlled medications strictly as directed. To receive refills, you must follow the terms of our Controlled Medication Agreement. Early refills or replacement of lost/stolen prescriptions are generally not provided. Compliance checks—including Prescription Drug Monitoring Program (PDMP) reviews and drug screenings—will be conducted per Montana law and clinical judgment.

Communication

• Portal & Phone: For routine matters between appointments, call 406-317-5201 or send a message via the Charm Health Patient Portal. Please direct all portal messages to our Practice Manager. Messages that require your provider's attention will be forwarded immediately. In some cases, you will be asked to schedule an appointment to discuss your concern.

• We return messages and voicemails within 1 business day. Complex clinical issues may require scheduling an appointment.

Confidentiality & Safety

Please see our Notice of Privacy Practices for additional information regarding your privacy

• Privacy & HIPAA: Your medical information is protected by state and federal law. Information is disclosed without consent only as legally required: suspected child, elder, or vulnerable-adult abuse; explicit risk of harm to self or others; court orders; or mandatory public health reporting.

• Minor Patients: If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

• Facility Safety: Archived video monitoring may be used in common/public areas of the office for safety. No recording occurs in clinical treatment rooms.

• Social Media Boundaries: To protect your confidentiality and maintain professional boundaries, your provider does not accept friend or contact requests on social networking platforms (e.g., Facebook, LinkedIn).

Emergencies, Termination, & Patient Rights

• Emergencies: This practice does not provide 24-hour crisis coverage. In a crisis or mental health emergency, call 911, call/text 988, or go to the nearest emergency room immediately. Do not rely on portal messages or voicemail.

• Ending Treatment: You or your provider may end treatment at any time. If treatment is terminated because goals are met, you are noncompliant, you default on payment, or you need a higher level of care, your provider will discuss the reasons and offer referral sources.

• Patient Rights: You have the right to respectful care, full information regarding your treatment, access to your records as allowed by law, and the right to file a complaint with the Montana Board of Nursing (301 S. Park Ave., 4th Floor, Helena, MT 59620 | 406-841-2300).

ACKNOWLEDGMENT & CONSENT FOR TREATMENT

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