A clinical chart is maintained describing your condition and your treatment and progress in treatment, dates of appointments, fees for sessions and notes describing each session. Your records will not be released without your written consent, unless in those situations as outlined in the Confidentiality Agreement section above.
Cancellations, Missed, and Same Day Re-scheduling Appointments
Once your appointment is scheduled, you will be expected to pay for the office visit for it unless you confirm with one following:
1. New Patient Appointments: MINIMUM 48 BUSINESS HRS (2 BUSINESS DAYS) NOTICE (WEEKENDS ARE NOT INCLUDED) New Patient Appointmemnts- If not compliant with plicy, them the full cost of the appointment is due: $385 will be charged from the card on file
2. Established/Follow Up Appointments: MINIMUM 48 BUSINESS HRS (2 BUSINESS DAYS) NOTICE (WEEKENDS ARE NOT INCLUDED) Established/Follow Up Appointments- If not compliant with policy, then the full cost of the appointment is due: $150 will be charged form the card on file.
3. Rescheduled Appointments MINIMUM 48 BUSINESS HRS(2 BUSINESS DAYS) NOTICE If not rescheduled in advance, then the following applies:
a. Same Day Rescheduling: $150 will be charged to the card on file
b. Within 24 Business Hours (1 Business Day): $100 will be charged to card on file
c. Valid Methods To Cancel or Reschdule Appointments: Email: email@example.com Call the office: 713-840-7956 (MTH: 9am to 5pm, FRI: 9am to 3pm) Fax: 713-840-7957 or In Person
After Hours Contact
In the event of un urgent psychiatric matter outside of regular hours you may contact the on-call provider by call the office and following the appropriate prompts on our telephone operator.
a. This service is for emergencies ONLY that cannot wait till the next business day (i.e., suicidal thoughts, thoughts of harming others, serious medication reactions, or unusual bahavior that may be of harm to yourself or others). Non-emergency matters (i.e., medication refills, schedulling or billing issues) must be addressed via email or by leaving a voicemail message for clinic staff.
b. Calls Placed for non-emergency issues will result in being chared a $50 fee for afterhours care
Insurance Changes, Billing and Payments Policy:
a. Notification to the office of 2 Business days is REQUIRED prior to your appointment with ANY cahnge of insurance. The office cannot verify your insurance for mental health benefits the day of your appointment. Even if your insurance requires "no-precertification" or there is no deductible, the office cannot verify benefits on the day of your visit. If notification is not giving to the office within 2 Business days in advance to your appointment, the "full fee" for your visit will be due. Unless, the office manager and/or the supervising doctor modifies this policy. This will be the only notification that will be received.
b. Our office accepts several commercial insurances only. Our office DOES NOT file insurance claim forms for insurances we are not contracted and credentialed with. We will be glad to give you a receipt, which includes all of the information necessary for filing claims with your insuranance company.
i. As a courtesy to you, we will bill your primary insurance company directly for medical services rendered. While we make a good faith attempt to verify coverage, we are not able to guarantee that the information fiven to us by your insurance is correct. We encourage you to call your insurance plan directly if you have any questions about covered services.
ii. In addition, you will be responsible for payment of all non-covered services at the time thay are rendered. If your insurance subsequently pays for services that were first treated as non-covered, you will be reimbursed. Know that it is your responsibililty to notify our office if your have any insurance changes
iii. All office fees are due at the tome service (co=payments, deductibles, non-covered services, lack of medical coverage). This office accepts cash, MasterCard, Visa, Discover, American Express and debit cards for your convenience. Our office does NOT accept checks. If your account has payment overdue for over 60 days, we have the option of using legal means to secure payment, including collection agencies or small claims court. In most cases, the only information we would be providing would be your name, nature of services provided, and amount due.
Termination of Care
At times, termination of care between a patient and provider is necessary. Termination of care may occur at any given time and may be initiated by either the patient or the provider.
Issues discussed with your provider are important and are generally legally protected as both confidential and “privileged.” However, there are limits to the privilege of confidentiality. These situations include: 1) Suspected abuse or neglect of a child, elderly person or a disabled person, 2) when the doctor believes you are in danger of harming yourself or another person, or you are unable to care for yourself, 3) if you report that you intend to physically injure someone the law requires the doctor to inform that person as well as the legal authorities, 4) if the doctor is ordered by a court to release information as part of a legal involvement in company litigation, etc., 5) when your insurance company is involved, e.g. in filing a claim, insurance audits, case review or appeals, etc., 6) in natural disasters whereby protected records may become exposed or, 7) when otherwise required by law. You may be asked to sign a Release of Information so that the doctor may speak with other mental health professionals or to family members.
If you are concerned about some of your information, you have a right to ask us, to not use or share some of your information for treatment, payment or administrative purposes. Such request must be made by writing.
After you have signed the Consent Form, you have the right to revoke it at any time, by writing a letter informing us that you no longer consent to the use and disclosure of your Personal Health Information. On receipt of your letter, we will comply with your wishes about using or sharing your information from that time on.
- Late Arrival to Appointments is NOT permitted: If you arrive more than 10 minutes to your scheduled appointment you MAY be asked to reschedule for another day and time: SAME DAY rescheduling fee of $150 will be charged to the card on file. Any amount of time that you are late to your appointment will be deducted from the TOTAL TIME slot you are scheduled for. Additionally, you understand that you may be seen by a different Medical Doctor or Nurse Practitioner on this appointment.
- Please note that insurance companies will often NOT reimburse for missed appointments or appointments that are cancelled late.
- We realize no one can predict emergencies or disasters. Courtesy is however, requested. If you arrive more than 10 minutes late, please be aware that there is the possibility that your appointment may be reschduled, as not to inconvenience the next scheduled patient.
- Please note than in the event of a missed, rescheduled, or cancelled appointment, your medications may not be refilled.
- Also, reminder calls/texts/emails are a courtesy. You are responsible for your appointment whether your reminder was received or not
Text message, e-mail, and telephone reminders are a courtesy service only. You are responsible for your appointment Whether a reminder is received or not.
Emails: Please remember that email has the privacy of a postcard. Before you send an email, be cautious with what you're disclosing. Emails cannot be a means of managing a crisis, since one cannot always be aware email arrival. Neither, can one have access to email on a permanent basis. If it is a medical emergency, please contact 911. Otherwise, We can still be contacted via emaikl for non-immediate matters.
Please be aware that we are not in the office every day, but do commit to return your voicemail messages within two business day. If you have a life-threatening emergency, experience worry that you will hurt or kill yourself, or have a concern that you are going to hurt or kill someone else, please leave us a message and call 911 immediately. We suggest leaving hospital emergency department, law enforcement, and poison control numbers by your telephone or programming them into your cell phone.
Faxes: Faxes are reviewed during normal business hours and are responded within 72 hours. Priority of requested medications from pharmacy are taken into consideration when responding to each fax. Medication changes will not be accepted.
Forms, Letter & Other Professional Services
Any other professional services that requires longer than 5 minutes such as:
a) report writing, B) telephone conversations (non-emergency), preparation of treatment summaries, or d) time spent performing any other service that will be charged $95.00 for each 10-minutes increment, like the fee for treatment
i) ONLY with prior medical physician approval, Temporary Disability and FMLA paperwork will be charged STARTING AT $125.00. Letters such as 504 letter, accommodation letters, form letters, and medications letters will be charged at a STARTING RATE OF $95.00.
Prescriptions & Refills
Please allow 5 business days to completed the medication refill request. Our office does not refill medications on weekends or holidays. If you notice that you running out of medications and you do not have refills remaining, you must call and schedule an appointment as soon as possible, Please allow time (2-3 weeks) to schedule your follow-up appointments in order to guarantee medication refills. The providers will authorize phone requests for medication refills at their discretion, based on the patient's best interest and safety. If you recently saw the doctor and need a refill please contact your pharmacy and request a refill
- Please note that if you need a same day refill there will be a $55.00 fee. If you need a rewrite of a contolled substance (including expired prescriptions) there will be a $35.00 fee.
- Prescriptions for a stimulant medication (Schedule II controlled substance) cannot be called or faxed into the pharmacy and must be filled within 21 days. If you ae requiring a rewrite, the expired prescription can be reissued.
- Medications will only be refilled for current patient who maintain their reqularly scheduled appointments. Your refill will be denied if you have not been seen within the time frame recommended by your provider.
Prior authorizations are a courtesy service. While we do our very best to secure coverage for prescription medications, it is ultimately the patient's responsibiling to contact their insurnace company to determine which medications are covered or to request appeals for potential coverage.
Treatment of Minors
*Please see addendum regarding treatment of minors of divorced parents or non-parent consent for additional policies related to these unique Minor 17 years of age or younger must be accompanied by a parent or legal quardian. Under no circumstances will medication changes be authorized without parent or legal guardian present.
Appointments Rescheduled by the Clinic
At times our office may call to reschedule your appointment due to conflict with your provider's schedule. Providers at our clinic authorize their patients to see a Nurse Practitioner in this situation on the appointment date. If rescheduled, please check your medications to be sure you have enough to last until the date you return.
You are responsible for complying with your prescribe medication regimen and being adherent to appointments. You Should not make any medication adjustments without consulting with your provider first. It's your responsibility to inform your provider of all medications you are taking, including over-the-counter medications and supplements. Medication adjustments cannot be made via phone or email and require a in clininc visit.