Restorative Mindset & Behavior Institute PLLC (and its subsidiaries)

Restorative Mindset & Behavior Institute PLLC (and its subsidiaries) (the "Practice") is required by federal law (HIPAA) to maintain the privacy of your Protected Health Information (PHI) and to provide you with notice of our legal duties and privacy practices with respect to PHI. We may use and disclose your PHI for treatment, payment, and healthcare operations without your additional authorization. Examples include coordinating care with other providers, billing your insurance, and quality-improvement activities. We may also use or disclose PHI without authorization where required or permitted by law, including: public health activities, reporting of abuse/neglect, judicial and administrative proceedings, law enforcement purposes, organ donation, research where approved, to avert a serious threat to health or safety, military and national security, and workers' compensation. You have the right to: inspect and copy your records; request amendments; request an accounting of disclosures; request restrictions or confidential communications; receive a paper copy of this notice; and file a complaint with the Practice or with the U.S. Department of Health and Human Services without retaliation. Contact: 252-483-6150 | info@rmbigroup.org

Appointments and Cancellation Policy: Patients are expected to keep scheduled appointments. Cancellations require at least 24 hours' notice. A fee of $75 will be charged for any missed (no-show) appointment, and a fee of $75 will be charged for any cancellation made less than 24 hours before the scheduled appointment time. These fees apply to in-person, telehealth, and phone visits and are the patient's personal financial responsibility (insurance does not cover them). Communications: Routine clinical communications are conducted through the secure patient portal. Phone and email communications are limited and may not be monitored continuously. For medical emergencies, call 911 or go to the nearest emergency department. For mental health crises, call or text 988 (Suicide & Crisis Lifeline). Prescription Refills: Allow 3-5 business days for refill requests. Controlled substance refills require an active treatment relationship and may require an in-person visit. Discharge from Practice: The Practice reserves the right to discharge any patient for non-payment of accumulated balances, repeated no-shows, violation of the Controlled Substance Agreement, or behavior in violation of the Patient Code of Conduct. Patient Portal: A patient portal account will be created for you. You are responsible for keeping login credentials confidential.

Under the federal No Surprises Act, you have the right to receive a "Good Faith Estimate" explaining how much your medical care will cost when you are uninsured or do not plan to use insurance for your care. You are entitled to a Good Faith Estimate in writing at least 1 business day before your medical service. You can request one at any time before scheduling. If you receive a bill that is at least $400 more than your Good Faith Estimate, you may dispute the bill through the federal patient-provider dispute resolution process. To request a Good Faith Estimate or for questions, contact: 252-483-6150 | info@rmbigroup.org. More information: www.cms.gov/nosurprises.

I voluntarily consent to receive psychiatric and/or behavioral health evaluation and treatment from Restorative Mindset & Behavior Institute PLLC (and its subsidiaries) and its providers. Treatment may include: diagnostic evaluation; medication evaluation, prescribing, and monitoring; psychotherapy and counseling; coordination of care with other providers; laboratory testing as clinically indicated; and referrals. Benefits, Risks, and Alternatives: Treatment carries potential benefits (symptom reduction, improved functioning, increased insight) and potential risks (medication side effects, emotional discomfort during therapy, no guarantee of outcome). Alternative options include declining treatment, seeking treatment elsewhere, and other modalities. I understand I may discontinue treatment at any time, though abrupt discontinuation of medication can be dangerous and should be coordinated with the provider. Telehealth: Telehealth services have the same standards as in-person care. Limitations include possible technical disruptions and inability to perform a physical exam. In an emergency I will call 911 or 988. Pediatric Consent (when applicable): If the patient is a minor, the parent/legal guardian provides consent on the minor's behalf and confirms legal authority to do so.

To support accurate clinical documentation, all visits — in-person, telehealth, and phone — may be audio-recorded and processed by an AI-assisted transcription service. Recordings are used solely to generate and verify clinical notes and are protected as PHI under HIPAA. Recordings and derived transcripts are stored securely and retained per applicable law and Practice policy. I understand I may ask questions about this process at any time.

I understand that I am financially responsible for all charges for services rendered to me (or my minor child), regardless of insurance coverage. I am responsible for providing accurate and complete insurance information. Insurance verification is a courtesy and does NOT guarantee payment by the insurer. Failure to disclose accurate primary, secondary, or other insurance information may result in denied or unpaid claims, for which I will be personally responsible. Copays, coinsurance, deductibles, self-pay balances, and prior balances are due at the time of service. The Practice does not offer payment plans. Past-due balances may be referred to a collection agency, and continued failure to pay may result in discharge from the Practice (where consistent with applicable law). By signing this intake, I authorize my insurer to pay benefits directly to the Practice and authorize the release of medical information necessary to process claims.

Mutual respect is a core value of Restorative Mindset & Behavior Institute PLLC (and its subsidiaries). We are committed to providing care in a safe, respectful, and supportive environment for patients, providers, and staff. Verbal abuse, threats, harassment, discrimination, intimidation, profanity directed at staff, or any inappropriate behavior toward staff, providers, or other patients will not be tolerated and is grounds for immediate discharge from the Practice. Crisis support: dial 988.

Controlled substances are prescribed at the sole discretion of the provider. The provider may decline or delay prescribing controlled substances when, in clinical judgment, doing so is appropriate. Patients with a history of substance use disorder may be required to engage in concurrent treatment with a substance-use counselor. By acknowledging this agreement (if applicable to my care), I agree to: take the medication exactly as prescribed; obtain all controlled-substance prescriptions from this Practice and fill them at one designated pharmacy; consent to Prescription Drug Monitoring Program (PDMP) checks; submit to random urine drug screens; safeguard the medication from loss, theft, or diversion (lost/stolen medication will not be replaced); attend all required follow-up visits; and not request early refills. Violations may result in discontinuation of controlled-substance prescribing and/or discharge from the Practice.