Ramia Gupta, MD.
1000 Duke Street, Alexandria, VA. 22314
Tel: 703-470-5844 Fax: 703-683-0431
Practice Policies
Welcome to my practice. The following contains information with regards to my
practice policies. Please review the following information and feel free to ask
questions.
Evaluation:
1. All new patients to the practice will receive an Initial psychiatric
examination. This will include a detailed history and may require more than
one session. This may also include a request for previous medical,
psychiatric, and psychological records. In addition I may also ask that you
obtain a physical examination and laboratory tests, especially if I am
prescribing medications to you. In addition I will ask for a copy of your
recent physical examinations and laboratory tests, and other collateral
information.
2. I will request that you sign a Release of Information authorization form
giving me consent to communicate with your other healthcare providers,
including both current and former mental healthcare providers.
3. At the end of the evaluation, I will provide you with treatment
recommendations.
Confidentiality:
The patient-doctor relationship is confidential and cannot be released to a third
party without specific authorization by the patient. However there are certain
circumstances that are an exception. Following are certain situations in which
the physician is require to breach confidentiality:
1. Virginia law requires the mandatory reporting of Child or Elder abuse to the
appropriate authorities even when this is revealed in the context of the
doctor patient relationship.
2. If the patient poses a serious danger to himself/ herself or a danger to others.
1
Ramia Gupta, MD
1000 Duke Street, Alexandria, VA. 22314
Tel: 703-470-5844 Fax: 703-683-0431
3. The physician is obligated to warn a person if they think that this person is
likely to become a victim of violence at the hands of the patient.
During the initial evaluation, I will ask my patient to sign a consent form indicating
that they have given their permission to the lawful use and disclosure of their
protected health information for treatment, payment, and healthcare operations.
Treatment:
Upon deciding your treatment, we will discuss your treatment plan. This may
include medication management, psychotherapy or a combination of both treatment
modalities.
If I am only prescribing medications to you and your receiving therapy from another
provider, the following are my requirements in order for you to receive the best
medical/mental health care possible:
a. You must provide consent for full communication between your therapist
and myself.
b. If a non-medication emergency arises, please contact your therapist directly,
after which you may contact this office.
I will ask that you continue to receive appropriate medical care on a regular basis
from your primary care physician. This should include both a physical examination
and necessary laboratory tests.
Medication management and refills:
I will provide medication management during scheduled appointments only. This
will include a discussion of the medications being prescribed, responses to
medications, and other treatment modalities if applicable.
If a patient is running out of medications and does not have a scheduled
appointment before the medication runs out, the patient should then call this office
to schedule an appointment.
2
Ramia Gupta, MD
1000 Duke Street, Alexandria, VA. 22314
Tel: 703-470-5844 Fax: 703-683-0431
In the event that the medication needs to be called in outside of a scheduled
appointment, there will be a $ 15 charge.
In this case, all of the following information must be provided: Patient’s name and
date of birth, name and dosage of medication, telephone number where the patient
can be reached, and the name and telephone number of the pharmacy.
Please note that refills for federally controlled medications such as stimulants like
Ritalin and Adderal CANNOT be called in or faxed to a pharmacy. They must be
written on a paper prescription and are dispensed for only 30 days.
Appointments, Cancellations, and Late arrival policies:
Please provide two business days notice if you need to cancel or reschedule your
appointment. If you provide this, you will not be charged. Monday appointments
must be cancelled by 5.00pm on the prior Friday.
If you provide less than two business days notice, you will be charged the full
appointment rate.
Unlike a general medical office, each patient’s session is reserved specifically for him
or her. Therefore each session needs to begin and end promptly on time. I am
unable to extend a session beyond the allotted time. Thus, if a patient arrives late for
his/her scheduled session, that time is lost from their session. If I am late, I will
reduce the patient’s fee proportionally or make up the time when mutually
convenient.
If I cancel an appointment, you will not be charged. I will take true emergencies into
consideration.
Coverage:
When I am on vacation, another psychiatrist will be available to cover my practice.
I will leave the covering psychiatrist’s contact information on my voice mail. I will
inform you as far advance as possible of scheduled vacation time.
Contact Information:
My office phone number is 703-470-5844. For non-emergency concerns, please call
and leave a message on my answering service.
3
Ramia Gupta, MD
1000 Duke Street, Alexandria, VA. 22314
Tel: 703-470-5844 Fax: 703-683-0431
In general, you can expect a call back within the next twenty-four hours. I request
that patients leave their full name, the time that they called and a call back number.
If a patient does not hear from me within the next business day, I request that you
call back again. Please ensure that you leave a clear message.
In the event of a psychiatric emergency, please call 911 or go directly to your
nearest emergency room. When you arrive at the hospital, please have the health
care provider contact me as soon as possible.
Billing and Fee Schedule:
Payment is due in full at the time services are rendered. In the case of a two visit
Initial Evaluation, full payment is due at the end of the first visit. I only accept
payments in the form of cash and personal checks. If a personal check is returned
for insufficient funds, there will be a $50 charge. If a second check is returned for
insufficient funds, I will no longer be able to accept personal checks from the
patient.
At this time, I participate in only selected healthcare insurance programs. If I am
unable to acceptance your insurance, I can provide you with a superbill that
contains the necessary information to submit to your insurance for reimbursement.
Fees:
1. Initial evaluations consist of a 60 minute detailed interview. I charge $350 for the
initial evaluation. This may require two sessions. Full payment is due at the end of
the first session.
2. Medication management visits are 30 minute sessions. I charge $200 for each
session.
3. Therapy sessions are 45 minute sessions. I charge $200 for each session.
4. Combined medication management and psychotherapy sessions are 50 minute
sessions. I charge $250 for each session.
4
Ramia Gupta, MD
1000 Duke Street, Alexandria, VA. 22314
Tel: 703-470-5844 Fax: 703-683-0431
I am happy to provide patients with a written report upon request. There is an
additional fee based on the time that it takes for me to prepare such a report. My
hourly rate for report writing is $150 for each hour. Review of documents including
hospital records are billed at $100 per hour.
I do not bill for routine telephone calls including calling in prescriptions to
pharmacies. For more detailed calls, I will charge a prorated rate based on my
general rate.
My aim is to provide my patients with the best possible care for their mental well
being. I encourage you to ask questions regarding your condition and treatment
including the risks and benefits of treatment.
If for any reason you are dissatisfied with the treatment provided, I encourage you
to talk with me directly as I believe that this will enhance a therapeutic alliance
between us.
In the rare event that I feel a patient would be more appropriately treated by
another provider (due to poor treatment adherence or a breakdown in the
therapeutic relationship), I will provide the patient with the name of an alternative
provider. I will continue to provide treatment for up to 30 days including a
prescription for a 30 day supply of medications. This is to prevent any interruption
of patient care.
__________________________________________
Patient name
_______________________________________
Patient signature
_________________________________________
________________________________________
Signature of Parent / Guardian
Date
_________________________________________
Physician’s signature
_________________________________________
Date
5