Welcome to our practice!
The following information is provided to our patients to assist in understanding the policies and
procedures at our office. We strive to provide you care which is both comfortable and of the highest
quality. Attached to this Patient Agreement is the required Notification of Patient Rights document
now required with the passage of the federal “medical records privacy act” known as HIPAA. We are
required by law to give you a copy of this document and to secure your signature indicating you have
received a copy of it. Laws such as these are important and we have tried to inform you about your
rights in plain simple language. Please read this agreement and do not hesitate to ask any questions
you might have about this information.
Patients are seen by appointment only unless an emergency situation dictates otherwise- the
appointment time given is reserved for you. Please give at least twenty-four (24) hours notice if you
must cancel your appointment. Sometimes illnesses and emergency situations happen which prevent
you from keeping your appointment and we are understanding of these infrequent occurrences but please
call as soon as you can. In the absence of such circumstances you will be charged a no-show fee
with a minimum of $50.00 up to the fee for your scheduled appointment for any appointments not
canceled 24 hours in advance. Please understand that insurance companies will not pay this fee- it will
be your full responsibility to pay these charges. These charges will be due prior to scheduling
another appointment. If you miss three or more appointments you may be discharged from the office.
FEES AND PAYMENTS
Co-payments, deductibles and/or outstanding balances are due at the time of service. If
necessary payment arrangements can be made for larger balances and such agreements will have to
be honored in order to continue treatment. There may be special fees for certain services such as filling
out paperwork, court appearances, consults, etc and will be discussed with you prior to the service
being provided. All accounts that require the need for a collection agency and/or attorney involvement
for payment will be assessed an additional penalty of 50% of the outstanding balance.
Call at least 2-3 days prior to running out of medication in case there are issues with your request.
TELEPHONE CALLS AND EMERGENCIES
Although you have regularly scheduled appointments, there may arise occasions when you need to
talk to us between appointments. Please call during regular office hours and we will return your call as
soon as we can. If you leave a message that the office staff can not handle we will forward your
message to your physician and you will receive a call back when he responds to your message.
Please remember that the physician is not always readily available due to seeing patients in the office
or not in the office at the time of your call. If your call is an emergency please inform the staff
We have twenty-four (24) hour coverage for emergencies outside normal office hours. Please use this
service for emergencies only. If the on-call staff is called on your behalf after hours you may be
charged a minimum $35 fee up to $75 depending on the length and type of call. If the on-call staff is
notified and your call is not an emergency you will be charged a $35 fee for a non-emergency call back
even if your request is not granted. Please remember that medication refills are not emergencies.
Insurance companies will not pay this fee- it will be your full responsibility to pay these charges.
These charges will be due at your next appointment or prior to scheduling another appointment.
Your physician should provide you with enough medication and refills until your next appointment. If you
need refills due to missed or rescheduled appointments please call the prescription line and leave
detailed information including your name, your call back number, your doctor’s name, pharmacy phone
number, medication needed and dosage. If you need an appointment or have an outstanding balance,
this will need to be handled prior to refilling any medications. Please understand that routine
medication refills will not be called in after hours or on the weekends.
INSURANCE USAGE/ISSUES OF CONFIDENTIALITY/PRIVILEGED COMMUNICATION
If you elect to have your third party insurance filed, you will be signing a release of information to our
billing service. This service handles all claims, statements and information on your account until your
account balance is zero. The following information will be forwarded for this purpose- your personal
identify information, your insurance information, dates and length of sessions, diagnosis and office notes
if required by your insurance carrier. As you know insurance company policies have changed
tremendously in regard to reimbursement for service. Many plans require initial pre-certification of care
before you can use your benefits. It is your responsibility to make sure such pre-certification
requirements are met by you if you elect to use your insurance benefits (i.e. if you have any“gate
keeping” mechanisms such as calling insurance for approvals) Nearly all insurance companies will
require participation in utilization review procedures. We will be giving your insurance carrier only the
information that is necessary to certify care and reimbursement.
With these exceptions, unless you specifically sign a release of information authorizing us to talk to
someone, all communications here are kept private, confidential and privileged. We strive to maintain
the sacredness and privacy of your confidential communications with us.
PATIENT AND/OR GUARDIAN RESPONSIBILITY WAIVER
We have your insurance claims filed as a courtesy to you; it is your responsibility to notify this office
when you have a policy/insurance change or information update. This includes your personal address
and phone number. We want to be clear that if you do not notify this office of your insurance changes
and updates within your timely filing limits, you are responsible for the balance on the account. This
signed agreement between you-the patient and/or guardian/guarantor supersedes all other contractual
obligations we may have with your insurance carrier in accordance with timely filing of your claims.
YOUR INFORMED CONSENT TO CARE AND TREATMENT
We have provided this information to you in the hopes of fully informing you about the policies of this
office and some of the parameters of care you will receive here, such as the importance of
confidentiality. Since such limitations are always a function of your particular problem in question, we
invite you to discuss your treatment plan with us. After we have met to discuss your concerns we will
construct an individualized treatment plan and share it with you so that we have a plan and goal for the
problems we are going to address.
Should you have any questions please feel free to discuss any of these matters with us in more
By signing the PATIENT AGREEMENT FORM you acknowledge to having read, understood
and agreeing to these policies and procedures. Your signature also acknowledges your
informed consent for treatment