We appreciate the opportunity to serve as your Behavioral Healthcare provider. We are committed to providing the best care possible. Please take a moment to review and sign our patient information and financial policy.
Confidentiality: All information discussed during the initial visit or subsequent treatment is considered confidential. A written Release of Information will be obtained in the event your provider is required to discuss your care with others. Upon admission you will be provided with a copy our HIPAA Notice of Privacy Practices and Handbook of Consumer Rights.
Change of information: Please provide us with any changes regarding your address, telephone number and insurance as soon as possible.
Referrals: If you are currently enrolled in a managed care plan (i.e., HMO) a referral from your Primary Care Physician (PCP) may be required prior to service delivery.
Appointments: Appointment times are held exclusively for each patient. Please help us serve you better by keeping your regularly scheduled appointment. Outstanding balances must be brought current before future appointments are granted.
Missed or Cancelled Appointments: You will be charged $35 for appointments missed and/or not cancelled within 24 hours of appointment time. This charge will be billed directly to you. Self-Pay and 3rd Party Beneficiaries Only
Late Arrivals: If you are more than 10 minutes late, you may be asked to reschedule.
Prescriptions: Please ensure that you have an adequate supply of medication (samples or prescription). Please call your pharmacy for all prescription refill requests and allow 48 hours processing time.
Treatment plan: It is important to maintain your treatment by complying with your provider’s treatment regimen, i.e., taking medications and keeping scheduled appointments. If you are not seen in at least 6 months, we will consider your case closed and the provider-patient relationship terminated. If you desire to re-open your case after that time you may require a re-evaluation along with any appropriate fees to see your provider.
Patient Dismissal: If you fail to meet your financial obligations or are non-compliant with your treatment plan you will be discharged from services. You will be notified by regular and certified mail that you have 30 days to find alternative behavioral health care.
By signing below, I acknowledge that I have received a copy of the HIPAA Notice of Privacy Practices, Handbook of Consumer Rights: Mental Health Services and that I understand and agree to the terms and conditions as set forth in this policy.