OFFICE POLICIES and AGREEMENTS
SELF PAY / FORMS / LATE CANCEL FEES
Psychiatric Evaluation with MD/NP (45min) $180
Medication Management with MD/NP (15-20 min) $60
Psychotherapy Evaluation (50min) $150
Follow up Psychotherapy Visit (50min) $80
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Forms (Disability, FMLA, Returned Checks): $60
Medical Record Copies: $10, plus $0.50 per page
Late Cancel / No Show (24hr notice required to avoid fee): $60
BILLING AGREEMENT
The patient/guardian will be obligated to pay for all services rendered if the patient’s insurance company denies the claim for any reason. There
are many reasons that an insurance company might deny a claim, including lack of medical necessity, lack of prior authorization, and lack of
referral by a Primary Care Physician.
The patient/guardian agrees to pay any co-pays or co-insurance AT THE TIME OF SERVICE. The patient will not be able to see his or her service
provider without making this payment. Post-dated checks will not be accepted.
If there is a balance on the patient’s account, the patient/guardian will be required to pay the Minimum Due Amount prior to meeting with the
service provider. This will equal the amount of the co-pay for that day’s service and either 25% of the balance or $25.00, whichever is greater.
The adult accompanying a minor (or guardian of the minor) is responsible for payments for the child at the time of service. Unaccompanied
minors will be denied nonemergency service unless charges have been preauthorized to an approved credit plan, charge card, or payment at the
time of service.
PRESCRIPTION POLICY
If you wish to make a change to your medication, you will need to schedule an appointment with your doctor. Prescription refills should be
primarily obtained during doctor appointments. Prior to leaving your appointment, please ensure that you have enough refills to last until your
next appointment. If you must obtain a prescription refill between appointments, you will need to ask your pharmacy to fax a request to our
office at 804-423-1393. It is your responsibility to ask your pharmacy to send the request early enough so that you will not run out of medication.
Please do not call the On-Call Clinician to request refills.
The refill request will be processed within 48 business hours after your pharmacy faxes the request. This means, for instance, that if you make a
request on Friday afternoon, it may be the following Tuesday afternoon before the request is processed.
Refill requests will be denied if: you have an outstanding balance and have not established a payment plan with the office manager or are not
honoring your payment plan.
I guarantee payment for all charges incurred by the patient that are not covered by insurance. I further agree to be responsible for all costs of
collection, including attorney’s fees/collection agency fees, in an amount equal to 33%, or more, of the then due balance, should this account be
placed in the hands of an attorney at law or collection agency due to delinquency in payment.
EMERGENCY POLICY
If you are experiencing a life threatening emergency and/or medication side effects causing shortness of breath, heart problems, severe rash, or
other life threatening ailments, please call 911 or go to your nearest emergency room. An after-hours clinician is on-call clinician for psychological
emergencies only. While the on-call clinician may be able to contact your medical provider regarding medication questions, this is not
guaranteed. Most, medication is managed only during regular business hours. On-call clinicians can help your identify and evaluate your options
in emergency situations. For the on call clinician call (804) 423 -1389 and follow the telephone prompts.
OFFICE POLICIES
Recipient’s Rights: I certify that I have received the Recipient’s Rights pamphlet and certify that I have read and understand its content. I
understand that as a recipient of services, I may get more information from the Office Manager.
Nonvoluntary Discharge from Treatment: A client may be terminated via nonvoluntary discharge letter if: (A) The client exhibits physical violence,
physical or verbal intimidation, verbal abuse of ANY other person, including doctors, clinicians, staff/support personnel, and other patients or
their families and friends, carries weapons, or engages in illegal acts at the clinic. Abusive phone messages or abusive verbal interactions over the
telephone are also cause for nonvoluntary discharge. (B) The client refuses to comply with stipulated program rules, refuses to comply
with treatment recommendations, or does not make payment and/or payment arrangements in a timely manner. (C) The client repeatedly
cancels, cancels late, or does not show up for appointments.
I agree to accept services under the above conditions: ______________________________________________________________
(Signature of patient or legal guardian)