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Patient Policy Agreement

1. Services are provided with the understanding that you (not an insurance company) are ultimately responsible for the cost of the services that you are purchasing. Insurance plans vary and not all services may be covered. You are responsible for knowing what services are covered by your particular plan, please check with your plan by calling the number on the back of your card before your appointment. If your need prior authorization for services, this must be completed before you are scheduled.

2. If your insurance does not pay your claim it will be your responsibility to contact them to resolve any issues of coverage or coordination of co-coverage. If you have a change in your insurance, it is your responsibility to notify the office as soon as possible to ensure that the correct company is being billed and that your account does not become past due.

3. The person signing below is the account guarantor and is accepting responsibility to pay for services rendered. This includes those provided to a child – regardless of custodial or legal agreements between parents.

4. Payment for deductibles, co-pays, uncovered services, or any balance due on your account are to be paid at the time of your – or your child’s – appointment. Please come, or send your child, prepared to do so. If you are not in a financial position to pay at the time of the appointment, we will be happy to reschedule the appointment for a more convenient time.

5. Accounts with unpaid balances over 90 days past the date of service will be given to an outside collection agency to bill and collect. An additional fee will be added to cover the expenses involved to do so. Your insurance will not pay for these additional charges.

6. If 12 months has passed since you were last seen, you will no longer be considered an established patient with us due to you not following up within the agreed upon amount of time.

7. Prescriptions will be written with enough refills to last until your next appointment. We recommend scheduling your next appointment at the end of each session so that we can be sure you are following your treatment plan and also do not run out of medication. My strict policies primarily reflect my concern for my clients’ well-being. Self-assessment of psychiatric symptoms can be difficult and requires quite a bit of practice and feedback, especially early in treatment.

8. Medication refills are done during the appointment time only. If something unexpected occurs, please have your pharmacy fax a refill request. Do not email or call about refills. Please allow up to 5 business days for the refill to be approved, if appropriate, and schedule an appointment as soon as possible.

9. Controlled substances such as benzodiazepines and stimulants are tightly regulated by the DEA. These medications can be very useful when indicated, but require more monitoring and must be part of a comprehensive treatment plan. If you do not stick to the agreed upon treatment plan, I will continue to work with you, but will not continue to prescribe controlled substances. There will be no early refills of controlled substances for any reason.

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