John W. Grace, M.D., P.A.
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General Psychiatry
Phone: (352) 795-2246
Caring. ​Private. Relaxing.
Compassionate Mental Health Care
General Patient Instructions
SAME DAY APPOINTMENTS
If you need to be seen come in before 10:30 a.m. on any regular business day. We will fit you in but there may be some wait time. Please see the first available provider.
In crises, reach out for the first available competent person, DO NOT wait for THAT ONE special person.
This will help stabilize you throughout life.
MESSAGING
Please sign up for electronic messaging within practice fusion. You will be able to send us private email-like messages. There may be some delay if the person the message is sent to is not working at that time. Utilize the clinic line at (352) 795-0356 if necessary. Life-threatening emergencies should always go through 911.
TAKE OWNERSHIP OF YOUR CONDITION BUT ALLOW US TO GUIDE YOU
You are seeking treatment because you have a problem we believe we can help you with.
"Help" is the qualifying word here.
Our assistance without your effort will be limited.
Not only do we need your effort, we need you to let us direct it. This may be the most important thing you can do to get better quickly. Let go of a little control. Allow us to direct your energy. Try to follow all of our instructions.
We are not trying to control you.
We are trying to give you greater control over your life.
We may not be able to help you if you don't allow us some influence in changing the way you live your life. Part of your mental health may be the life you’re trying to live.
TRACK OF YOUR SYMPTOMS AND SLEEP ON A DAILY BASIS
Most people are really inaccurate when reporting how they felt a week ago.
The best thing you can do to improve the quality of information you give us is keeping a mood chart.
There are many available on line.
There are apps for your phone (daylio).
At bare minimum, write down two numbers on your calendar every day. How many hours you slept? Your mood on a scale of 1-10 (1 is really bad, 5 is even and pleasant, 10 is way too good). We have a copy of the mood chart and sleep diary we recommend available on our website on the patient forms page.
BEHAVIORAL ACTIVATION AND CIRCADIAN INTEGRITY
People are supposed to be active in the day and shutting down in the evening.
Try to keep a good rhythm to your day with consistent mental and physical activity during daylight hours and calm shutting down as evening approaches.
The more consistently you do this the more stable you will be.
Avoid napping during the day. It can disturb the normal pattern of sleep and wakefulness.
Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal.
Exercise can promote good sleep.
Vigorous exercise should be taken in the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night's sleep.
Food can be disruptive right before sleep. Stay away from large meals close to bedtime.
WHAT IS HAPPINESS?
People often want to feel "happy." The truth is with our stimulus-overloaded society, many people have started to look for constant stimulation and "excitement" as the new "happy".
Perpetual excitement through video games, electronic stimulation, and intense interactions is probably not a sustainable form of mental health.
Peace and serenity as a baseline, with occasional excitement, is a far more achievable goal. Most people today probably need a little less stimulation and more contemplation which brings us to the importance of mindfulness.
CONSIDER BEING MORE MINDFUL
Expecting nothing while accepting and appreciating everything is the essence of mindfulness, viewing every interaction and experience in the most positive and productive way.
Mindfulness is a way of controlling and examining your thoughts and feelings that is helpful for not only minimizing the impact of negative events but also maximizing the appreciation of positive ones.
It helps us to survive when life is at its worst and thrive when life is at its best.
Please learn how to incorporate this way of thinking to minimize the impact of negative events and better appreciate positive ones. Our office has groups twice a week on Tuesday and Thursday at 3:00 p.m.
BALANCE YOUR IMPROVEMENT
There really are five ways that someone can improve: (SYMPTOMS, FUNCTIONING, INSIGHT, MEDICATION, STABILITY)
They can have fewer or less severe SYMPTOMS.
They can have greater FUNCTIONING.
They can have greater INSIGHT into their limitations.
They can be on less MEDICATION.
They can have more STABILITY.
Patients tend to focus on symptoms first, then functioning.
Therapists tend to focus on insight.
Doctors tend to focus on medications and stability.
All of these must be balanced.
The most important thing is NOT FORGETTING ABOUT#4.
Why? This is how people get in endless cycles of more and more medication. For example, Patient Jim feels bad symptoms while juggling three stressful activities. He goes to the doctor and gets medications. He goes to therapist and gets insight. He overall improves functioning and decreases symptoms. He comes back in three months with return of symptoms but he is now trying to juggle five things. So Jim thinks he needs more medication. We all want to have fewer symptoms, more functioning, and perfect insight. Sometimes the price with polypharmacy and instability is too high We need to keep all of these in mind.
MAINTAIN RELATIONSHIP WITH PRIMARY CARE
Most Psychiatric conditions worsen in states of physical neglect. Likewise Psychiatric conditions can worsen medical problems. Also please get labs on time when ordered. This is an important part of monitoring medications and also assessing underlying conditions that can appear to be psychiatric in nature but are really physical in nature.
NEW MEDICATIONS
- Maintain a relationship with one pharmacy that has an updated list of your medications.
- Always ask them to run an interaction profile with any new medication.
- Do not drive on a new medication before you know how it will effect you.
- Always practice birth control while on psychotropics.
- Monitor blood pressure weekly unless instructed to do so more often.
- Always read instructions, labels, and warnings from pharmacy and follow instructions unless specifically directed differently.
DIAGNOSIS IN OUR RECORDS
Diagnosis can be used for different purposes:
It can give a prognosis.
It can have legal ramifications.
It can direct treatment.
Here we are generally interested in the third. We use our diagnosis to direct treatment. Prognosis (which we will be happy to discuss) will likely be based on more factors than diagnosis. Legal ramifications or opinions are best determined by outside, independent parties and our diagnoses should not be used independently of a thorough review of the treatment record by a highly qualified professional.
Policies of John W. Grace, M.D. , P.A.
SUICIDAL THOUGHTS
Suicide is a serious complication of psychiatric conditions and suicidal thoughts can signify a psychiatric emergency. If you have thoughts of hurting yourself or others and worry about your ability to control such impulses you should go the nearest emergency room or dial 911. Outpatient clinic is not the appropriate place to manage an acute psychiatric emergency if you are not safe at this time.
APPOINTMENTS
Established patients take precedence for urgent appointments. That means your new appointment may be bumped. Many psychiatric offices book months in advance.
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We do not.
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We give new patients the first available appointment. That means there is the potential for a crisis (or more likely several crises) to make that appointment unavailable. We recommend hospitalization or our partial hospitalization program for patients that have urgent clinical needs that our timetable does not accommodate.
SEEING ONLY DOCTOR GRACE
Patients frequently request to see only Dr. Grace. Our office has employed a number of advanced practice providers over the years including physician assistants (PA) and nurse practitioners (ARNP). They are a valuable and necessary component of the healthcare team. We feel that patients should familiarize themselves with all providers in the practice in the occurrence that they had a crisis and only one of them was available to assist. Your health may depend one day on you reaching out to the nearest available person.
FIRST SESSION
The first session is a CONSULTATION ONLY. You will not be considered a patient of this office until both you and we agree after your first session there is some benefit to be gained from working together.
DO NOT rely on us to refill prescriptions or prescribe medications on the date of your first appointment. If you do not enter into a doctor-patient relationship after the consultation, we WILL NOT do so.
We may not be able to accept you as a patient for any number of reasons after reviewing the case. For instance there may be a conflict of interest with one or our employees or other patients. We may not be able to tell you why we cannot accept you. Please understand that this is simply the nature of psychiatric care and in no way a reflection upon you.
APPOINTMENT RESPONSIBILITIES and TERMINATIONS
- All patients prescribed stimulants and buprenorphine (Adderall, Ritalin, Vyvanse) need to be seen every sixty days.
- All patient prescribed medications should be seen every three months.
- Any hiatus of treatment greater than six months, a patient’s file will be closed unless other arrangements have been arranged in writing and documented in the patient’s chart.
- If another outpatient provider assumes prescription responsibility for psychotropics (medications to treat psychiatric conditions) you are considered a patient of that provider rather than this office.
PAYMENT / LATE CANCELLATIONS:
Our office requires 24 hour notice for cancellation of appointments. Failure to provide will result in the patient being charged a fee of $50.00. Patients are expected to maintain a zero balance. We reserve the right to charge a 1.5% monthly finance charge for balances more than thirty days overdue.
CHARGE FOR PHONE CALLS
We do not charge for brief phone calls regarding medication updates or refills. Longer, therapeutic phone calls will be charged at the following rates
which insurance does not usually cover.
Brief Session (5-10 minutes): $35.00
Moderate Session (11-20 minutes): $65.00
Extended Session (21-30 minutes and up): $100.00
CLINIC ASSOCIATED WITH ACADEMIC CENTERS
Members of our staff are on clinical faculty at the University of South Florida Department of Psychiatry and Lincoln Memorial University Debusk School of Osteopathic Medicine in Harrogate Tennessee.
Our office uses social workers, psychologists, nurses, physician assistants and nurse practitioners, there also may be students from physician, physician assistant, and nurse practitioner programs in the office. All members of the team will work with you and have access to your clinical information throughout your treatment course. We cannot guarantee you will see the same provider of the team at every appointment. You may be with Dr. Grace or end up seeing a nurse practitioner or physician assistant who is familiar with your case.
OUR OFFICE SUPPORTS PSYCHIATRIC RESEARCH
Research is a critical part of our mission at John W. Grace, M.D. , P.A. We have a commitment to discover better ways to help improve quality of life for our patients and others.
We encourage patients to have an open mind about research trials, see them as an opportunity to not only help themselves but also others. We understand research is a long-term commitment. We ask our patients to understand the same. One of the most critical issues regarding new treatments is how they perform over time. Commitment to the ongoing process allows us to continually monitor this.
FILLING OUT PAPERWORK IS A COMPLICATED PROCESS
When you ask us to sign a piece of paper you are asking for a medical opinion, an opinion we must be prepared to defend in a court of law.
A medical opinion is defined as :
"Statements from physicians and psychologists or other acceptable medical sources.”
The opinion of a treating physician should be afforded substantial weight.”
Hunter v. Astrue, 2009 U.S. Dist. LEXIS 92045 (D. Minn. Aug. 4, 2009)
What this means is not that you are asking us to simply sign a piece of paper (anymore than signing a deed to your house is simply a signature). You are asking us to commit ourselves to a position using our expertise that we are willing to defend in a court of law.
In these situations, we are obliged to review any paperwork very carefully. This involves time and perhaps additional testing. Insurances may not reimburse for this process and there may be substantial charges for it.
It is the policy of John W. Grace, M.D. to submit any and all paperwork to our document review center. You may be required to provide more information. There is a $50.00 charge for this process and it may take up to a week to return an answer. After reviewing the paperwork, several things may happen and you need to understand this before you start this process.
1. We may fill out the paperwork in a way that is detrimental to your position. This is particularly possible in cases of disability where there has been non-compliance (you haven’t tried all options, taken medications, or come as frequently as we have suggested).
We have to be honest and forthright in our opinion. For instance a disability statement may read,
“Patient is complaining of symptoms of severity that would make work difficult.
However; it is difficult to say within medical certainty that the patient is unable to work solely from mental condition as he/she has missed several appointments and not tried several treatment modalities we have recommend. In addition there has been some use of alcohol despite our recommendations against such.”
In cases like this, our relationship may deteriorate and necessitate the need for a transition to another provider if you feel that we did not give you the answer you expected.
2. We may fill out paperwork in a way that is supportive but not necessarily conclusive. For instance, if you are asking for an emotional support animal, our opinion may be written as followed.
“Patient is suffering from a condition that would benefit from a support animal to prevent deterioration and provide structure. This does not preclude other options for support (friendships, etc).”
3. It may be filled out as is.
4. There may be additional charges before it is filled out.
5. It may require a visit or additional procedures to fill it out.
6. We may not be able to be fill out at all.
7. We may require additional input from you and this input may not help the outcome in the way you desire.
Keep in mind when we fill out paperwork we may simply reference your medical records. There is no reason we should have to look through your medical records for the single piece of information that your attorney or insurance company is asking for.
Our records are kept using standards acceptable throughout the field. Our data presentation meets acceptable standards for the standard of care. If there is a fact or opinion required that is already located within your record then the answer to the question will simply be “see medical record.” If there is an additional piece of information required, it will be provided.
Please keep in mind, we are not trying to make things difficult for our patients. Organizations exaggerate to you how easy it is for us to sign things and stand behind them. This process means so much more than “Just have your doctor sign this.”
Dr. Grace’s current forensic rate is $350/hour for any document review, preparation, travel time, and testimony.
If deposition is required a half-day is blocked off with a retainer of $1500 (in advance) that is forfeited unless the deposition is cancelled more than 1 week prior to deposition.
John W. Grace M.D. P.A.
Confidentiality and HIPAA Privacy Policies:
Privacy Officer: Lisa Nalepa
- Confidentiality is waived if there is a real immediate threat to yourself or someone else.
- Certain diseases must be reported to the Health Department
- A Court Order may request these records.
- We are required to report cases of elder or child abuse.
- Under most circumstances no paper records released without approval.
- All paper records are locked up after close of business day.
- Some private information is shared with insurance companies as required for billing.
- Information will be shared with treating physicians and staff in order improve quality of care. In order to effect psychiatric treatment, families and physicians need to be occasionally involved for patient safety. An example of this policy would be if a family member called Dr. Grace stating that the patient was acting in an unusual way that sounded like hypomania. If the patient were on lithium for bipolar disease, Dr. Grace would likely stress the importance of hydration with the medication the patient is on as well as provide the family member techniques in dealing with a hypomanic person, releasing the minimum required information to aid in the situation. Your safety is our number one priority. And our office, while valuing both, puts patient safety in emergency and crisis above privacy.
- Our office utilizes “Practice Fusion” for medical records. A summary of their privacy practices may be obtained at www.practicefusion.com
PRESCRIPTION POLICIES
Governor Scott signed sweeping legislation on prescription drugs which took effect July 1st, 2018. This has resulted in increase responsibilities for offices and patients. Our updated prescription policies are as follows:
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Here are what we ask of established patients:
- We expect you to keep a copy of this and reference when prescribed new medication.
- Take medications as prescribed without any alcohol or drugs.
- Maintain a working relationship with a primary care physician so you can discuss
medical issues as they arise in my treatment.
- Understand that in women most medications can place the unborn fetus
at significant risk and agree to discuss plans for pregnancy with my
physician and practice proper, effective birth control.
- Do daily monitoring to aid in diagnosis and treatment. This may include a Mood chart
or Sleep Diary.
- Maintain a relationship with one pharmacy and ask that pharmacy to repeatedly perform
analysis of drug interactions.
- Refilling medication is a complicated process. To minimize errors we recommend the
following. Please have all prescriptions filled at your appointment.
- If you need medication called in please have your pharmacy send an
electronic request to Dr. Grace office and allow 72 hours for us to reply.
-Do not go without medication. Come in for urgent appointment any
weekday we are open before 10:30 a.m. or call Dr. Grace on his cell phone.
- All controlled substances (Class I-Class V) listed are prescribed by Dr.
Grace or a covering physician. All other medications listed below are
prescribed by either Dr. Grace, Physician Assistants, or Nurse
Practitioners under guidelines established in writing or practice by Dr.
Grace with other licensed providers.
- Additional requirements for controlled substances listed below.
CONTROLLED SUBSTANCE PRESCRIPTION POLICIES
With the legislative initiative of Governor Rick Scott, taking place on July 1st, 2018 regarding controlled substance prescribing, more stringent requirements for prescriptions of all CLASS I, II, III, IV, and V medications are being implemented.
Controlled substances of the following classes are prescribed by Doctor Grace.
Class I:
Medical Marijuana
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Class II:
Stimulants
(Dextroamphetamine (Adderall),, Atomoxetine (Strattera)
Lisdexamfetamine ( Vyvanse ) , Phentermine ( Adipex ) ,
Dextroamphetamine (Dexedrine)
Opioids
Buprenorphine (Suboxone, Subutex)
Class IV:
Hypnotics and Benzodiazepines:
(Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium),,
Clonazepam (Klonopin) Triazolam (Halcyon) Chlordiazepoxide (Librium),
Clorazepate (Tranxene) Ambien, Sonata, Lunesta, Temazepam (Restoril)
Wake Promoting Agents:
Armodafinil (Nuvigil), Modafinil (Provigil)
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Requirements of the Office for Controlled Substances Contract Signed Agreement to
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Bi-monthly visits for all controlled substances
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Randomized Drug Test to be completed
SAMPLE CONTRACT CONTROLLED SUBSTANCE
Patient Agreement to Participate in Controlled Substance Treatment
Initial, Sign and Date
As a recipient of a Controlled Substance at John W. Grace, M.D., P.A. , I
agree to accept this treatment contract _________
With controlled substances there are possible serious withdrawal and
relapse symptoms. ________
I agree it is my responsibility to keep my medication in a secure place. Lost
medication will not be replaced. __________
I understand it is a crime to sell, share or dispense my medication to
another and would result in termination. _____________
I will keep and be on time for all appointments and take medication as
prescribed understanding I may not receive it if I violate this clause.
________
I will provide urine for the purpose of toxicology screens at any time during
my treatment. ________
I will not mix with other medications, alcohol or other drugs of abuse. This
can be dangerous. ________
I understand that medication alone is not the sole treatment. I agree to
participate in creating and carrying out a treatment plan. ______
If I decide to stop controlled medication therapy I will work to taper slowly
with treatment team. _______
I may be terminated from this office if I am treated with a controlled
substance and I am not seen every 120 days. This may place me at
substantial risk for withdrawal and require me to enter emergency care.
_______
FOR WOMEN: Controlled substances have not been approved for use by
pregnant women. If I decide to or accidentally become pregnant, I will
immediately notify doctor.______
Printed Name Initials Signature Date
______________________________________
Doctor Grace: ____________________
WITNESS: _______________________
Client Name:_____________________________________________________________
Email: _____________________________________________________________
Address:___________________________________________________________
Telephone:__________________________________________________________
DOB: _____________________________
SS#:__________________________
Insurance:___________________________________________________________
Secondary Insurance:_____________________________________________________
Emergency Contact & Relationship:
Name:
Address:
Phone:
MEDICATIONS COMMONLY PRESCRIBED AND SOME ASSOCIATED RISKS
(SEE PACKAGE INSERT FOR FULL RISKS)
Anti Anxiety:
(Lorazepam (Ativan), Alprazolam (Xanax), Diazepam (Valium), Buspirone (Buspar), Clonazepam (Klonopin) Triazolam (Halcyon) Clonidine (Catapres), Prazosin (Minipress), Terazosin, Hydroxyzine (Vistaril), Propranolol
(Inderal), Tiagabine (Gabitril), Gabapentin (Neurontin), Pregabalin (Lyrica), Chlordiazepoxide (Librium), Clorazepate (Tranxene), Baclofen
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Chemical Dependence, Sedation, Impairment of Ability to Operate Heavy
Machinery, Cardiovascular Collapse, Memory Loss, Death in overdose, Do
not rapidly stop these medications or it could kill you. Do not operate
machinery when changes doses of these meds. Do not drink alcohol while
consuming these medications. Do not get pregnant on this medication
without discussing with physician. Damage to Fetus in Pregnancy.
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Alpha-Blockade Agents:
(Clonidine, Prazosin, Tizanidine (Zanaflex)
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Can both lower and increase blood pressure resulting in strokes and other
neurological symptoms. You need to monitor your blood pressure daily
while on these medications, never miss a dose unless instructed to and
coordinate your care with your primary care physician.
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Antipsychotics:
Haloperidol (Haldol), Ziprasidone (Geodon), Olanzapine (Zyprexa), Quetiapine (Seroquel), Aripiprazole (Abilify), Chlorpromazine (Thorazine), Fluphenazine, Perphenazine, Thioridazine, Thiothixene, Asenapine (Saphiris), Brexpiprazole (Rexulti), Cariprazine (Rexulti), Clozapine (Clozaril), Iloperidone (Fanapt), Lurasidone (Latuda),
Paliperidone (Invega), Pimavanserin (Nuplazid):
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Diabetes, Weight gain, Irreversible Movement Disorders, Increased risks of
death in the elderly compared to sugar pills, Liver damage, Heart
Problems, Seizures. Cataracts. Skin Rash. Do not get pregnant on this
medication without discussing with physician. Damage to Fetus in
Pregnancy.
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Antidepressants:
Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), Venlafaxine (Effexor), Mirtazapine (Remeron), Bupropion (Wellbutrin, Zyban), Citalopram (Celexa), E-Citalopram (Lexapro), Amitriptyline (Elavil), Nortriptyline (Pamelor), Clomipramine (Anafranil), Doxepin (Sinequan), Vilazodone (Viibryd), Phenelzine (Nardil), Vortioxetine (Trintellix), Venlafaxine (Effexor), Desvenlafaxine (Pristiq), Levomilnacipran (Fetzima), Duloxetine (Cymbalta)
Seizures, Increased thoughts of suicide, Nausea, Headache. Sexual
dysfunction, Confusion from Low Sodium. Do not get pregnant on these
medication without discussing with physician. Damage to Fetus in
Pregnancy.
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Lithium:
Heart Problems, Sudden Death, Neurological Problems including seizure
and tremor, Kidney Failure, Thyroid Problems, Weight Gain, Parathyroid
problems. You need to have your blood monitored on lithium. Do not get
dehydrated on this medication. Do not get pregnant on this medication
without discussing with physician. Damage to Fetus in Pregnancy.
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Stimulants:
(Dextroamphetamine (Adderall), Armodafinil (Nuvigil), Modafinil (Provigil), Atomoxetine (Strattera) Lisdexamfetamine (Vyvanse), Phentermine (Adipex), Dextroamphetamine (Dexedrine)
Weight Loss, Suicide, Depression, Heart Attack, Stroke, High Blood
Pressure. Do not get pregnant while on these medications.
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Anticonvulsants:
(Tegretol, Valproic Acid, Depakote Topiramate (Topamax), Keppra (Levetiracetam):
Seizure, Hair loss, Tremor, Liver failure, Pancreatitis, Hepatitis, Weight
Gain, Bleeding problems, Life threatening rash. You should not operate
heavy machinery when titrating new doses of these meds. You should
have lab draws on these meds. Do not get pregnant on these medications
without discussing with physician. Damage to Fetus in Pregnancy.
Suicidal Thoughts and behavior.
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Lamictal:
Death from Life Threatening Rash. Liver problems. Do not get pregnant
on this medication without discussing with physician. Damage to Fetus in
Pregnancy. Suicidal Thoughts.
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Neurontin:
Seizures, Increase in Suicidal thoughts. Do not get pregnant on this
medication without discussing with physician. Damage to Fetus in
Pregnancy. May cause sedation. Do not operate heavy Machinery while
changing doses. Suicidal thoughts.
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Sleep agents:
Ambien, Sonata, Lunesta, Restoril. Suvorexant (Belsomra) Triazolam (Halcion), Temazepam (Restoril)
Chemical Dependence, Sedation, Impairment of Ability to Operate Heavy
Machinery, Cardiovascular Collapse, Memory Loss, Death in overdose, Do
not rapidly stop these medications. Do not operate machinery when
changes doses of these meds. Do not drink alcohol while consuming these
medications. Do not get pregnant on these medication without discussing
with physician. Damage to Fetus in Pregnancy. Can cause sleep walking
or eating or driving.
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Trazodone:
Trazodone can cause a painful erection or genital swelling that can lead to
damage to the tissue. This can occur at any time in treatment but is
relatively uncommon. It can also cause sedation and drop in blood
pressure increasing your risks of falls.