Amanda S. Kleinman M.D.
980 N Michigan Ave, Ste 1400, PMB 1477, Chicago, IL 60611
Fax: 708-575-8665, Phone: 773-220-6555,
amandakleinmanmd@gmail.com
INFORMATION FOR NEW PATIENTS
Welcome: I greatly appreciate the opportunity to get to know you and offer you help to the best of my ability. If
you have any questions about the contents of this letter or any other aspects of your evaluation and/or treatment
with me, please bring them up when we meet.
Appointments and Cancellations: I schedule all appointments myself. If you are calling to schedule or reschedule an appointment, please leave me some dates and general times that will work best for you. If you
cannot keep an appointment and inform me later than 6:00pm the day prior to the appointment, it creates an
unfortunate circumstance for me and other patients who are waiting for appointments. Therefore, if I receive
notice about your decision to cancel an appointment LATER than 6:00 PM the day before the appointment,
you will be charged the FULL amount for the missed appointment. Insurance companies do not reimburse
cancellations, so you will be responsible for the entire charge. If needed, you can leave a message at 773-2206555 to cancel on the weekends or holidays.
Fees and Payment: Fees are discussed at the beginning of treatment and may be adjusted every January 1 as
needed. Fees for visits are based on time increments of time (for psychotherapy) and level of complexity (for
medication management). Letters, forms, disability paperwork and other ancillary administrative requests will be
assessed a flat fee of $50 unless the paperwork is completed at the time of the visit.
Telephone conversations that last longer than 10 minutes may be subject to my pro-rated hourly fee of $300/hour
($5 per minute). I will give notice when the 10 minute increment is approaching so that patients can choose
whether to continue as a phone session or pause and save any further discussion for the next visit. Insurance does
not usually cover these charges.
I am able to accept Debit, Credit, and HSA cards, including Visa, MasterCard and Discover. If you are paying by
check, it will save time if you have the check made out before we meet. You can make it payable to "Amanda S.
Kleinman M.D."
Insurance and Managed Care: I am only “in-network” with Blue Cross/Blue Shield PPO. I am not “in-network,”
with any other insurance companies or government insurers such as Medicare and Medicaid.
Blue Cross/Blue Shield PPO: Please supply me with your Policy/Account number (usually 3 or more
letters followed by a series of numbers) and your Group number. I will check your eligibility for Outpatient
Mental Health services prior to your visit. You may have a copay, which will be due at the time of service. Please
come prepared to pay the copay at that time. If you want to know what your copay will be, please call the patient
information phone line on the back of your card.
Other insurance companies: I am “out-of-network” with other insurances, but some patients may be
able to get partially reimbursed for my services through their insurance provider. In this case, I will provide a
receipt for the service rendered and payment collected that can be submitted to the insurance company for
reimbursement. To see whether your insurance company has an out-of-network benefit, you can call your
insurance company and discuss the following information:
 Let the company know that you are planning to obtain “outpatient mental health” treatment from a
psychiatrist who is “out-of-network”
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Ask if the company will reimburse you for any of this treatment
Ask if there is a deductible to pay prior to reimbursement
Ask if there is a maximum charge covered, i.e., the “Usual and Customary Fee Allowable” by the
insurance company (if so, this will influence what you are reimbursed)
Ask how much you will be reimbursed after the deductible is paid (usually a percentage of the total
charge or a percentage of the “Usual and Customary Fee Allowable” by the company)
Ask if there are any limits of coverage or reimbursement, e.g., number of sessions per 6mos or 12mos,
total reimbursement amount per year?
Medicare and Medicaid: I do not participate in either of these programs. If you receive treatment from me it
will not be reimbursed by either these programs. If you are a Medicare beneficiary and decide to pay privately for
treatment with me you must sign an agreement documenting that you will not apply for reimbursement from
Medicare. This agreement is required by Medicare. I have an agreement form available and can review it at our
appointment.
Prescriptions and Refills: If I am providing medications as part of the treatment, I will e-prescribe the
medication or provide a written prescription by the end of the visit. We will always try to schedule appointments
to occur before you run out of medication, however if you see you will soon be out of medication and we don’t
have a visit set up, please call me ASAP to set up a visit. If you do run out of medications before we are able to
meet, please call me ASAP and leave me a message with the following information:
 The medication name, exact dose and frequency of dosage (daily, twice per day, etc.)
 The name and phone number of a pharmacy convenient for you
 Phone numbers where I can reach you if I need to clarify any information
I will call in a refill as soon as possible. I ask that we not do this routinely since I need to meet with patients on a
regular basis to monitor the medication treatment.
Communication: The primary way to discuss emotional or psychiatric concerns is in session, face-to-face. With
the challenges of technology, face-to-face meetings are the only way to guarantee privacy. Phone calls, texting
and emails are best reserved for scheduling or changing appointments, making objective inquiries, obtaining
medication refills and updating basic information like address or insurance policy. Generally, the more a person
has to say, the more it should wait to be said in person at the next appointment.
In case of emergency, the best way to contact me directly is by calling my work cell phone, 773-220-6555. If I do
not answer, please leave a message and I will listen to it and respond at my next available opportunity, usually
within the hour. Please know that I do not answer the phone while I am in session with patients because I wish to
give each patient my undivided attention.
Please do not use email to contact me urgently. While I try to check email throughout the day, sometimes I
only have time to check it once a day.
If you start to feel acutely suicidal or homicidal, the best option will always be to call 911 or go to your nearest
Emergency Room.
August 2014