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Complete our simple form - we'll confirm insurance eligibility and schedule you with the right provider.

We ask for these details so we can verify insurance benefits and contact the correct person if we have questions.

1. CONSENT FOR TREATMENT
I voluntarily consent to receive behavioral health services from Frontier Psychiatry, including but not limited to:

• Psychiatric evaluation
• Medication management
• Psychotherapy or counseling
• Diagnostic assessments
• Crisis intervention
• Care coordination with other providers (with appropriate authorization)

I understand:

• The purpose of treatment is to improve mental health symptoms and functioning.
• No specific results can be guaranteed.
• I may refuse any recommended treatment or withdraw consent at any time.
• I have the right to ask questions about my treatment and my provider’s qualifications.

2. TELEHEALTH CONSENT
I consent to receive services via telehealth, which may include video, phone, or other HIPAA-compliant technologies.

I understand:

• Telehealth has benefits (easier access, convenience) and risks (technology failures, privacy limitations).
• My provider will verify my physical location at each session.
• I must inform my provider if I relocate to a different state or am no longer in MT, ID, AK, WY, or NV.
• Emergencies: I must provide a current physical address and emergency contact at every visit so my provider can assist me if I am in crisis.

State-specific requirements

Idaho: I understand I am consenting to telehealth services pursuant to Idaho Code § 54-5701.

Alaska: Telemedicine may be used when clinically appropriate (AS 08.64.170, AS 08.68.700).

Nevada: I authorize the use of telehealth as defined in NRS 629.515.

Montana & Wyoming: Both states permit telehealth for behavioral health with patient consent.

I may withdraw telehealth consent at any time.

3. CONSENT FOR MEDICATION MANAGEMENT
If medication is recommended, I understand:

• All medications have potential risks, side effects, and interactions.
• I should discuss concerns with my provider before starting or stopping medications.
• My provider may review my prescription history using state Prescription Drug Monitoring Programs (PDMPs) as required by law.
• I must tell my provider about all substances I take (prescribed, OTC, supplements, and non-prescribed).

4. CONSENT FOR PSYCHOTHERAPY
If I receive psychotherapy, I understand:

• Therapy can involve discussing distressing thoughts or experiences.
• Progress depends on many factors including my participation.
• The therapeutic relationship is professional, not personal.
• I may discontinue therapy at any time.

5. LIMITS OF CONFIDENTIALITY
My information is kept confidential except when disclosure is required or permitted by law, including:

• Suspected abuse or neglect of a child, elder, or vulnerable adult
• Danger to self or others
• Court orders
• Mandatory reporting for certain threats (e.g., Idaho “duty to warn”)
• Coordination of care (only with appropriate authorization)

For patients receiving substance use treatment:
Information identifying you as receiving SUD services is protected by 42 CFR Part 2. A separate Release of Information must be completed for any disclosures.

6. CONSENT FOR ELECTRONIC COMMUNICATION (TEXT/EMAIL)
I consent to receive:

• Scheduling messages
• Appointment reminders
• Billing communications
• Care coordination messages via text, email, or secure messaging.

I understand these channels may not be fully secure and I may opt out at any time.

 

7. CONTROLLED SUBSTANCE TREATMENT AGREEMENT (AS APPLICABLE)
If I am prescribed controlled medications (stimulants, benzodiazepines, etc.), I understand that:

• My provider may check PDMP databases
• Early refills, lost medications, or misuse may result in discontinuation.
• I may be asked to complete urine drug screens.
• I must use medications only as prescribed.

8. MINOR CONSENT (as applicable; based on state laws)
Parent/Guardian Consent
I affirm that I have legal authority to consent for this minor and provide documentation if requested.

Minor Assent (recommended age 12+)
I agree to participate in treatment and understand my rights to privacy within legal limits.

State notes:

Montana: Minors 16+ may consent for outpatient mental health in certain circumstances (MCA 41-1-402) without parent/guardian approval.

Alaska: Minors 16+ may consent to limited mental health treatment (AS 47.30.690) without parent/guardian approval.

Idaho, Wyoming, Nevada: Parental/guardian consent generally required except in emergencies.

 

9. PATIENT RESPONSIBILITIES & EMERGENCY PLAN
I agree to:

• Provide accurate contact and location information at each visit
• Notify my provider of medication side effects, worsening symptoms, or suicidal thoughts
• Call 911 or go to the nearest emergency room if I am in immediate danger

10. CONSENT & SIGNATURES
By signing below, I acknowledge that I:

• Have read and understand this Master Consent
• Have had the opportunity to ask questions
• Consent to treatment and related services
• Understand that I may revoke consent at any time

 

FINANCIAL RESPONSIBILITY ACKNOWLEDGMENT

I acknowledge that I have received and understand the following information regarding financial responsibility for medical services:

1. PAYMENT RESPONSIBILITY

I understand that I am financially responsible for all charges incurred for medical services provided to me or my dependent, regardless of insurance coverage. This includes, but is not limited to:

2. INSURANCE COVERAGE

I understand that:

• Filing insurance claims is a courtesy provided by this Group
• I am responsible for providing accurate, current insurance information
• Changes in insurance coverage must be reported immediately
• I am responsible for obtaining any required pre-authorizations, referrals, or certifications
• I am responsible for understanding my insurance benefits, including deductibles, co-payments, and co-insurance
• Services not covered by my insurance plan are my responsibility

3.  GOOD FAITH ESTIMATES:

You have the right to receive a “Good Faith Estimate” explaining how much your medical and mental health care will cost.

If you are uninsured, or if you choose not to use insurance for your services, you are entitled to receive a Good Faith Estimate of expected charges before your appointment or before any services are provided.

This estimate will outline the anticipated cost of evaluation, medication management, therapy, or other services.

You may request a Good Faith Estimate at any time. If you receive a bill that is at least $400 more than your Good Faith Estimate, you have the right to dispute the bill.

For questions or to request an estimate, please contact our office at (406) 200-8471.

 

4. PAYMENT TERMS

• Co-payments are due at the time of service.
• Deductibles and co-insurance amounts are due upon receipt of statement.
• Payment is expected within 30 days of statement date unless prior arrangements have been made. 
• Returned checks will incur a fee of $30.00.
• No Show Fees and Cancellations less than 24 hours:
• New Patient = $100
• Established Patient, 1st Offense = $50Established Patient, 2nd+ Offense = $25

5. FINANCIAL HARDSHIP

If you are experiencing financial difficulty, please contact our billing department immediately to discuss payment plan options:

Contact: Billing Department Phone:  (406) 200-8471 option 3

 

6. COLLECTION ACTIVITIES

I understand that accounts with unpaid balances may be:

• Referred to collection agencies
• Reported to credit bureaus
• Subject to legal action for collection
• Charged reasonable attorney fees and collection costs

7. MEDICARE/MEDICAID PATIENTS

If applicable, I certify that the information I have provided regarding Medicare/Medicaid coverage is correct. I understand that I am responsible for:

• Medicare deductibles and co-insurance amounts
• Services not covered by Medicare/Medicaid

8. ASSIGNMENT OF BENEFITS

I hereby assign all medical insurance benefits to which I am entitled to the healthcare provider for services rendered. I authorize the provider to:

• File claims on my behalf
• Receive payment directly from my insurance carrier(s)
• Appeal denied claims as appropriate
• Release medical information necessary for insurance processing

9. AUTHORIZATION FOR TREATMENT

I authorize the healthcare provider and designated staff to:

• Perform medically necessary diagnostic procedures and treatments
• Administer medications as ordered by my physician
• Provide emergency treatment if I am unable to consent

10. MEDICAL RECORDS AND PRIVACY

I acknowledge that I have received a copy of the Notice of Privacy Practices and understand how my medical information may be used and disclosed. I understand my rights regarding my medical information under HIPAA regulations.

11. GUARANTEE AND CONSENT

By signing below, I acknowledge that:

• I have read and understand this financial consent form
• I agree to be financially responsible for all charges incurred
• The information I have provided is accurate and complete
• I will notify the provider of any changes in my insurance or contact information
• I consent to the medical treatment described above

 

FRONTIER PSYCHIATRY
NOTICE OF PRIVACY PRACTICES
Effective Date: September 1, 2025

THIS NOTICE DESCRIBES HOW MEDICAL, BEHAVIORAL HEALTH, AND SUBSTANCE USE DISORDER INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW CAREFULLY.

A. PURPOSE OF THIS NOTICE
Frontier Psychiatry (“Frontier,” “we,” “our”) is committed to protecting the privacy and security of your health information. We are required by federal and state law—including the Health Insurance Portability and Accountability Act (HIPAA), the 42 CFR Part 2 Confidentiality of Substance Use Disorder Records rule, and state behavioral health privacy laws—to maintain the privacy of your health information and to provide you with this Notice of Privacy Practices (“Notice”).

This Notice applies to all services provided by Frontier Psychiatry, including telepsychiatry, therapy, care management, and substance use disorder (SUD) services across all states in which we operate. It describes how we may use and disclose your information, your rights regarding your information, and our legal duties.

This Notice applies to:

• All Frontier employees, contractors, clinicians, residents, students, volunteers, care managers, and business associates.
• Any individual authorized to access or enter information into your Frontier electronic health record (EHR).

The most current version of this Notice will always be available at:
https://www.frontier.care/privacypractices

B. HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION WITHOUT YOUR WRITTEN PERMISSION
We may use or disclose your health information for the following purposes, as permitted by law. Whenever possible, we follow the minimum necessary principle, meaning we limit the information shared to what is needed for the purpose of the disclosure.

1. Treatment
We may use and disclose your information to provide, coordinate, or manage your care. This includes communication among your treating clinicians, such as psychiatrists, nurse practitioners, therapists, care managers, and other healthcare professionals involved in your treatment.

Because Frontier provides care through telehealth, your information may be shared electronically to support secure virtual care.

We may also involve trainees or supervised students involved in your care with your knowledge and permission.

2. Payment
We may use or disclose your information to bill for our services and to obtain payment from you, your insurance plan, Medicaid, Medicare, or another payer. This includes:

• Prior authorizations
• Determining eligibility
• Claims processing
• Appeals and utilization review

3. Health Care Operations
We may use or disclose your information for routine business operations necessary to run our practice and improve quality of care. Examples include:

• Quality assessment and improvement
• Training and supervision
• Customer service and patient engagement
• Care coordination and care management programs
• Data analytics and reporting (using de-identified or limited data sets when possible)
• Credentialing and auditing

Frontier uses technology partners—including electronic health record vendors, secure communication tools, AI-supported transcription services, and care management platforms—that may access information under Business Associate Agreements that require high privacy and security standards.

4. Telehealth Operations
Because Frontier operates through telehealth, we may use and disclose your information to:

• Verify your location and eligibility before each session
• Provide technical support related to telehealth platforms
• Ensure secure electronic transmission of video, audio, or messaging
• Support remote workforce access using secure, encrypted systems
• Frontier providers may access your information remotely from secure environments while delivering telepsychiatry services.

5. Health Information Exchange (HIE), e-Prescribing, and Care Coordination Networks
We may share information with:

• State Prescription Drug Monitoring Programs (PDMPs)
• Health Information Exchanges (if active in your state)
• e-prescribing networks such as Surescripts
• Laboratories, pharmacies, hospitals, or primary care providers

Only the minimum necessary information will be shared.

6. Family, Friends, and Support Persons
If you agree—or do not object—we may disclose information to people involved in your care or who help pay for your care.
If you are unable to communicate (due to emergency, crisis, impairment), we may disclose information based on our best professional judgment.

C. USES AND DISCLOSURES PERMITTED OR REQUIRED BY LAW
We may use or disclose your information without your written authorization for the following purposes, when permitted by law:

• Public health activities (e.g., reporting communicable diseases)
• Reporting abuse, neglect, or domestic violence
• Health oversight audits or investigations
• Legal proceedings, court orders, or subpoenas (with required safeguards)
• Law enforcement purposes
• Coroners, medical examiners, or funeral director
• Organ and tissue donation
• Research under approved protocols
• Serious threats to health or safety
• Disaster relief
• Military or national security activities
• Workers’ compensation programs

D. SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER INFORMATION (42 CFR PART 2)
If you receive Substance Use Disorder (SUD) evaluation or treatment at Frontier, your SUD records are protected by 42 CFR Part 2, which provides stricter confidentiality than HIPAA.

Under Part 2:

• We cannot disclose your SUD information to anyone—including other healthcare providers, law enforcement, or insurers—unless you sign a specific written authorization or another narrow legal exception applies.
• Redisclosure is prohibited. Anyone receiving Part 2 information from Frontier is legally notified that they may not share it again without your permission.
• Electronic SUD records are specially tagged and protected in our systems.
• You may revoke authorization at any time, unless we have already acted based on it.
• Federal or state law may require reporting of certain incidents such as suspected child abuse or medical emergencies—but only limited information will be disclosed.

E. WHEN WRITTEN AUTHORIZATION IS REQUIRED
We will not use or disclose your information for the following purposes unless you provide written authorization:

• Most uses of psychotherapy notes
• Marketing that involves financial compensation
• Sale of health information
• Substance Use Disorder information protected by 42 CFR Part 2
• Sharing your information with employers
• Other non-routine uses not covered in this Notice

You may revoke your authorization at any time in writing.

F. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the following rights:

1. Right to Inspect and Receive Copies
Including electronic copies of records stored in our EHR.

2. Right to Request Amendments
If you believe any information is incorrect or incomplete.

3. Right to an Accounting of Disclosures
A list of certain disclosures we have made.

4. Right to Request Restrictions
Including limiting disclosures to your health plan for services paid out of pocket in full.

5. Right to Request Confidential Communications
You may request communication by email, phone, text message, secure portal, or at specific addresses.

6. Right to a Paper Copy of This Notice

7. Right to Breach Notification
You will be notified of any breach of your unsecured information.

G. GOOD FAITH ESTIMATE NOTICE (NO SURPRISES ACT)
If you are uninsured or choose not to use insurance, you have the right to receive a Good Faith Estimate of expected charges before services are provided.

You may request a Good Faith Estimate at any time.

H. FRONTIER’S RESPONSIBILITIES
We are required to:

• Maintain the privacy and security of your health information
• Notify you following a breach of unsecured PHI or Part 2 information
• Abide by the terms of this Notice
• Notify you of material changes to this Notice
• Only use or disclose your information as described in this Notice

I. CHANGES TO THIS NOTICE
We may change this Notice at any time as permitted by law. Changes apply to all existing and future health information. Updated versions will be posted on our website and available upon request.

J. QUESTIONS OR COMPLAINTS
If you have questions or believe your privacy rights have been violated, you may contact:

Frontier Psychiatry Privacy Officer
1601 Lewis Avenue, Suite 102
Billings, MT 59102
Phone: (406) 200-8471

You may also file a complaint with:
U.S. Department of Health & Human Services, Office for Civil Rights
https://ocrportal.hhs.gov/ocr/portal/lobby.jsfPhone: 1-800-368-1019

You will not be retaliated against for filing a complaint.

ACKNOWLEDGMENT OF RECEIPT
I acknowledge that I received a copy of Frontier Psychiatry’s Notice of Privacy Practices.