Patient Attestation Agreement

Name
Office Policy and Patient Attestation: Services Provided: We provide a range of services including psychiatric evaluations, psychotherapy, medication management, and consultations. Patient Responsibilities: Patients are responsible for following their treatment plan which includes making and keeping appointments and taking medication as prescribed. If you cannot keep an appointment, you must cancel it at least forty-eight hours in advance or on Thursday in the case of a Monday appointment to avoid being charged the full fee for the appointment. Charges for late cancellations and missed appointments are not covered by insurance and are the responsibility of the patient. Be sure to reschedule any missed or cancelled appointments. After Hours Emergencies: We provide continuous psychiatric coverage, twenty-four hours a day, seven days a week. One member of the group is always on call to handle urgent matters when your provider is not available. When possible, contact your provider during regular working hours. Leave a brief message describing the nature of your call and telephone numbers where you can be reached either with a staff member or on your provider’s voicemail or patient portal. Talk with a staff member in cases of emergency. Calls after hours should be limited to emergencies and directed to the answering service at 512-404-9076. They will page the provider on call. If you have not heard from the provider within fifteen minutes, call the answering service again. Routine refills are not considered an emergency and are subject to a charge. Controlled substances are not prescribed by on call providers. Prescriptions: Prescriptions are written at scheduled appointments and should last until your next appointment, or a length deemed necessary by your provider. If you need a refill, contact your pharmacy to send a request to the office. If you need a new prescription, you must contact your provider. There will be a charge for controlled substance prescriptions written between appointments. Insurance: Our billing staff will assist you with payment and insurance matters. If your provider is in network with your insurance plan, we will file the claims for covered services. You must provide a copy of your insurance card and are responsible for your co-payment at the time of services. If your provider is not in network with your insurance plan, we will not file an insurance claim for you, however, you may be able to file on your own for “out of network benefits”. Our billing staff can advise you regarding this process. It is your responsibility to verify your insurance and benefits coverage. You may be charged in full for services not covered by your insurance plan (This will not occur in cases where the contract between your provider and the insurance company forbids it.). You may be billed for telephone calls, messaging, authorizations, copies of your medical record, consultations with other providers or attorneys, or for preparation of reports, letters, or forms. Office Visits: The charge for the initial consultation with your provider must be paid in full at the time of scheduling the appointment. Any payment subsequently received from a third party will be credited to your account or refunded. You are also responsible for payment in full at the time of follow up visits, except when the service has been preauthorized by your insurance plan. In this case you are responsible only for your co-payment. Please schedule your appointments at least a month in advance so you will have a selection of times that are convenient for you. If you wait until the last minute to schedule an appointment, it may be several weeks before your provider has an opening. We make every effort to work patients in on short notice in cases of emergency. Payments: If you are unable to make payments as required by the above policy, please discuss the matter with your provider and the billing staff. Special payment schedules may be arranged, when appropriate, at the discretion of your provider. Delinquent accounts are turned over to a collection agency if payment is three months overdue and special arrangements have not been made. We appreciate your cooperation with the office policies outlined above. Please discuss any questions or concerns with your provider or a member of the office staff. Our primary concern is the success of your treatment. Notice Concerning Complaints: Complaints about physicians may be reported for investigation at the following address: TMB PO Box 2018 Austin, TX 78768-2018