Welcome To Our Office!
Thank You for choosing our office for all your psychiatry needs. We are committed to providing you with the best quality and affordable
care. Listed below are our office and financial policies. Please take the time to read them thoroughly, ask us any questions you may have, once read
please sign in the space provided. At your request a copy can be provided to you.
1.
Emergencies – For emergencies after hours please call our answering service at 1-877-738-5580. The service will contact Arleta Brown.
Your call will be returned as soon as possible. NOTE: Prescription refills and referrals are not considered emergencies and will not
be done after hours.
2.
Late Appointments – If you are more than 15 minutes late to your appointment, you may not been seen that day and you might be
required to reschedule if your late arrival interferes with the appointment of other patients.
3.
Canceled Appointments - Our policy is to charge $10.00 for not canceling within 24 hours prior to your appointment. These charges will
be your responsibility and billed directly to you.
4.
No Call No Show – Our policy is to charge $20.00 for a no call no show missed appointment. Upon receiving 2 no call no show
appointments in 90 days you will be asked to seek psychiatry help elsewhere.
5.
Prescriptions - Refill requests will be handled by this practice within 48 hours after your request is received. Prescriptions will not be
called in after hours or on weekends. Prescriptions will not be handed out the same day they are requested. Prescriptions for CSII’s
are written after closing of the day they are requested and can be picked up the following day, after noon.
6.
Account Balances - All accounts with a balance will be required to make a monthly minimum $64.00 payment toward the balance before
being seen. If a payments has not been made within 30 days prior to an appointment, you will not be seen until a payment is made. Partial
payments will not be accepted unless otherwise negotiated with the Office Manager Jennifer or Nurse Practitioner Arleta Brown. Unpaid
balances over 90 days will be referred to a collection agency and you and your immediate family members may be discharged from
this practice.
7.
Co-Payments – Co-payments are required at the beginning of each visit, you will not be seen if your required co-payment is not paid or if
you have an outstanding balance due on your account.
8.
Returned Checks: For all returned checks there will be a $35.00 returned check fee. The returned check amount and returned check fee
must be paid in full before being see.
9.
Insurance and Payment Policy Proof of Insurance. If you fail to provide us with the correct insurance information at each visit, you may
be responsible for payment for all services provided.
10. Phones - Phones are answered during normal office days from 9:00a.m. To 6:00p.m. The office number is 1 (903)583-2901, messages may
be left at this number any day of the week, 24 hours a day. These messages are checked daily and the office Manager will do her best to
return calls within 24 hours during regular business hours Monday-Friday.
11. Test Results – Notifications for any laboratory work or other testing done through our practice will be given as soon as they are available
(usually within 5 working days from the test date). PLEASE DO NOT CALL THE OFFICE ABOUT THE RESULTS, we will call
you. Results must first be reviewed by the physician. You will then receive a call from the office’s assistant or a card in the mail with the
physician's instructions.
No further appointments will be scheduled until the missed appointment or no call no
show fee is paid in full nor will prescriptions be written or refilled if you are abusing any
of these rules or policies (Example: missed appointments or balance on account).
Patients Name: ____________________________________
Print: ___________________________________
Relationship to Patient: ___________________________________
Sign: _______________________________________
Date: _________________