Informed Consent & Provider Policies

Welcome to Modyfi®

Thank you for choosing Modyfi for your mental health and wellness needs. Founded in 2019, Modyfi stands for mind-body, functional, and integrative medicine, reimagining the mental healthcare experience with an individualized, holistic approach. We emphasize sustainable change, collaboration, and evidence-based care while identifying and addressing the root causes of mental health challenges. While each clinician may have their unique approach, our core values include:

  • Acceptance of people as they are

  • Collaboration and teamwork

  • Identifying and treating the root cause of issues

  • Using science and evidence to guide treatment

  • A willingness to challenge comfort zones for personal growth

  • Offering individualized treatment options

We will continually assess progress and outcomes, adjusting your treatment plan as needed to ensure effective care.

Risks & Benefits of Treatment

Therapy, medications, and lifestyle interventions are highly effective for many individuals. However, success depends on active participation, consistent attendance, and adherence to your treatment plan. While most patients see improvement, some may experience temporary discomfort as they work through challenges. We will discuss the risks and benefits of any recommended treatment.

Treatment Options & Medical Necessity

Modyfi offers:

  • Individual therapy

  • Couples counseling

  • Psychiatric medication management

  • Functional nutrition

  • Meal planning

  • Group medical appointments

    • DBT Skills Group

    • Intuitive Eating Group

    • Ketamine Group

All services are deemed medically necessary, meaning they:

  1. Address a covered condition (i.e., diagnosis), and

  2. Are expected to improve that condition based on clinical evidence.

Crisis & Emergency Protocol

Modyfi is not an emergency clinic and does not have staff available after hours.

  • Call 988 for mental health emergencies.

  • Call 911 or go to the nearest emergency room for life-threatening situations.

  • Ask the attending provider to contact your Modyfi clinician for continuity of care.

  • For urgent matters during office hours, call 833.366.3934.

Disability & Paperwork Policy

Modyfi contracts with Formacist® to complete short-term disability, FMLA, ADA accommodations, and various other letters and forms. Providers are not legally required to complete disability paperwork or accommodation requests and have clinical discretion to determine if such documentation is appropriate. To streamline this process and ensure accurate, timely completion, Formacist handles these requests.

More information can be found at https://modyfihealth.com/formacist

High Complexity ($150 first hour, $100 per additional hour) – Provider Signature Required

  • Workplace Accommodation Request (Federally Protected, Employer-Approved)

  • Educational Accommodation Request (Federally Protected, School-Granted)

  • Intermittent FMLA Request (Unpaid, Federally Protected)

  • Intermittent Leave Request (Unpaid, Employer-Approved)

  • Continuous Short-Term Disability Leave Request (Paid, Employer-Approved)

  • Continuous FMLA Leave Request (Unpaid, Federally Protected)

  • Continuous Medical Leave Request (Unpaid, Employer-Approved)

Moderate Complexity ($60) – Provider Signature Required

  • Return-to-Work Clearance

  • Return-to-School Clearance

  • Emotional Support Animal Letter

  • Letter of Support

  • Medical Leave of Absence Letter (Justification for school or work leave with estimated return dates)

  • Health Status Statement (General health assessment for insurance or legal purposes)

  • Modified Duty Recommendations (Assessing workplace accommodations)

  • Workplace/School Release Letter (Confirming need for time off and return date)

  • Therapy Attendance Verification (Confirming active therapy participation)

Simple Complexity ($30)

  • Confirmation of TreatmentCrisis & Emergency Protocol

Transition of Care & Medical Records

Patients are responsible for any expenses related to transferring medical records. However, under the CARES Act of 2021, patients can access their medical records at no charge (excluding therapy notes, which are protected by law).

Insurance & Payment Policies

  • Modyfi does not accept Medicaid or Medicare and does not accept Medicaid patients as self pay clients.

  • Insurance coverage varies by provider and state. We recommend calling your insurance company before scheduling to verify coverage.

  • Modyfi does not offer sliding scale fees. If you are unable to afford self-pay, we suggest exploring insurance options through HealthCare.gov.

  • Patients are ultimately responsible for all charges and fees.

Card on File & Payment Authorization

  • A valid payment method is required to be on file at all times.

  • You cannot see your provider without active payment info.

  • All major credit cards, including FSA/HSA, are accepted.

  • Check with your FSA/HSA company to confirm eligibility for our services.

  • Payment info can be added/updated through the patient portal.

  • Outstanding statement payments must be made promptly to continue care.

Insurance Copays, Coinsurance, & Self-Pay

  • Payment method is required for all initial evaluations, even with insurance.

  • Self-pay clients must prepay for sessions.

  • All copays and any self-pay fees not prepaid will be collected 48 hours before your scheduled appointment.

    • This is done as a convenience to you, this ensures financial responsibility is met ahead of time.

    • Insurance requires us to collect payment before the appointment to maintain compliance with billing regulations.

    • This process helps us serve more patients by reducing last-minute cancellations and scheduling disruptions.

  • Refund Policy: If you cancel at least 24 hours before your appointment, we will provide a full refund.

  • Any owed copayments, coinsurance, or uncovered services will be charged to your card on file at the time of service if not already paid.

Balances & Payment Plans

  • Insurance processing may result in a remaining balance.

  • This is common when starting care or after insurance renewals.

  • Any balance will be added to your statement after claims are processed.

  • Payment plans are available for large balances.

  • Past due balances over 180 days may be sent to collections with additional fees.

  • If you're experiencing financial hardship, contact us at billing@modyfihealth.com.

Cancellations, Reschedules, & No-Shows

  • Appointments must be canceled/rescheduled at least 24 hours in advance.

  • Late cancellations and no-shows are subject to fees:

    • $100 for 60-min therapy, 30-min psychiatry, and 30-min nutrition

    • $150 for 60-min psychiatry and 60-min nutrition

  • Patients arriving more than:

    • 10 mins late to a 30-min session or

    • 20 mins late to a 60-min session
      = No-show fee applies

  • Arriving more than 5 minutes late or leaving early may incur a $50 fee.

  • Automated reminders are a courtesy, but attending your appointment is your responsibility.

Minors & Custody

  • Modyfi does not perform custody evaluations or testify on custody-related matters unless court-compelled.

  • Our focus is on supporting mental health, not determining parental fitness or recommending custody arrangements.

Legal Requests & Subpoenas

  • Providers do not testify or provide court-related documentation unless court-ordered.

  • If court-ordered, a $3,000 retainer is required for all related services, per testifying provider.

  • Services include prep time, court appearances, travel, admin time, attorney fees, etc

  • Unused retainer fees will be refunded.

  • Rates:

    • $350/hour (in-office work)

    • $500/hour (out-of-office/court work)

    • $2,000/day minimum for court appearances, plus travel and incidentals

Children of Divorced Parents

  • Parents are expected to coordinate regarding appointments, transportation, etc.

  • Clinicians cannot act as messengers between parents.

  • Both parents have access to the child’s records unless rights have been revoked.

  • Progress and safety updates are shared; full session content may not be.

Minor Consent

  • Patients aged 18+ can consent to treatment independently.

  • In some states, minors may consent based on circumstances (emancipation, marriage, abuse).

  • Parents typically retain access to records unless parental rights are revoked.

  • Independent patients must have their own phone number and email to engage in treatment.

Legal Guardian Obligation

  • A parent or legal guardian must be present for Telehealth sessions unless the dependent can legally consent.

  • Absence of a guardian = appointment canceled + no-show fee charged.

Supervision of Services

  • Therapy, nutrition, and medical provider may be providing care under clinical supervision.

  • By engaging in these services, you:

    1. Consent to supervision of services.

    2. Consent to possible session recordings for supervisory review.

    3. Consent to sharing information with assigned clinical supervisors.

Discharge Policy

  • Patients inactive for 90 days with no contact may be discharged.

  • A warning will be sent with 30 days to respond or schedule an appointment.

  • After 90 days without response, administrative discharge may occur.

  • Patients in good standing may return to care at any time.

Controlled Substances & Prescription Policy

Historical Prescription Data

  • Providers may have access to your past prescriptions via our ePrescribe software, EHR, or other eRX platforms.

Controlled Substances via Telemedicine

  • Due to evolving federal regulations, Modyfi® currently prescribes Schedule II-V medications via telemedicine without an in-person visit. However, this may change at any time.

  • If regulations change, we have contingency plans in place to ensure continuity of care.

Benzodiazepines & Stimulants

  • Benzodiazepines (e.g., Xanax, Klonopin) are used for acute anxiety but are rarely prescribed long-term due to risk of tolerance and dependence.

  • Stimulants (e.g., Adderall, Ritalin) are only prescribed after ruling out alternative causes of focus, motivation, or hyperactivity issues.

Medication Refills

  • Patients must have follow-up appointments at least every 90 days for medication continuation.

  • Refill requests require 72 hours’ notice and are handled on a case-by-case basis.

  • You must use one pharmacy for all controlled substances.

HIPAA Privacy Practices

This Notice describes how Protected Health Information (PHI) about you (or your child) may be used and disclosed at Modyfi®. We are required by law to:

  1. Ensure your medical information is kept private,

  2. Provide this Notice about our legal duties and privacy practices,

  3. Follow the terms outlined in this Notice.

Use & Disclosure of PHI

We may use or disclose PHI for:

  • Treatment – To provide and coordinate care, including sharing with other Modyfi® providers.

  • Payment – If applicable, for insurance reimbursement.

  • Health Care Operations – Internal planning, quality review, and complaint resolution.

  • Public Health & Safety – Reporting diseases, abuse, or threats to health/safety.

  • Legal & Law Enforcement – When required by a court order or applicable laws.

  • Health Oversight & Special Government Functions – Ensuring compliance with regulations.

Your Rights Regarding PHI

  • Right to Access & Copy Your Records – You may request access or copies of your health records.

  • Right to Request Confidential Communications – You may request alternative means of communication.

  • Right to Restrict Disclosures – You may request restrictions, though we are not always required to comply.

  • Right to Amend Your Records – You may request corrections to inaccurate information.

  • Right to File a Complaint – Contact Modyfi® at 833-366-3934 or clinic@modyfihealth.com for concerns.

Patient Rights & Responsibilities

Rights

Patients have the right to:

  • Be treated with dignity and respect.

  • Actively participate in treatment planning.

  • Receive services in the least restrictive setting.

  • Have family involvement in care decisions.

  • Maintain privacy and confidentiality.

  • File grievances without retaliation.

Responsibilities

Patients are responsible for:

  • Treating providers and staff with respect.

  • Following their treatment plan and attending scheduled appointments.

  • Providing accurate information.

  • Making timely payments for services.

  • Understanding their rights and responsibilities.

Discharge & Re-engagement

  • If a patient has not received services in 90 days and does not respond to outreach, they may be administratively discharged.

  • Patients discharged in good standing are welcome to return to Modyfi® at any time.

Complaints & Grievances

  • Informal complaints can be discussed directly with your provider.

  • Formal complaints can be submitted via email at info@modyfihealth.com or by mail to:

    • 300 Delaware Ave., Suite 210, Wilmington, DE 19801

  • Urgent complaints (e.g., safety concerns) will be addressed within 48 hours.

Effective Date: March 2, 2019 | Last Amended: March 17, 2025