In case of an emergency, I authorize Arise Psychiatric Medical Group to contact the following individual on my behalf:

As the patient, or as legal guardian of a minor patient, I agree to pay for all services rendered. This office may bill my insurance carrier(s) as needed. I am financially responsible for all non-covered services. I authorize this office to release my information to process any requests.

If you have medical insurance, please be aware the benefits are an ESTIMATE only. Coverage may be different if your deductible or annual maximum has been met.

Please be aware, if you refuse to pay for your deductible prior to your appointment, services will not be provided to you. Staff will have to reschedule your appointment to a future date. Patients with 2 or more rescheduled appointments (due to unpaid deductibles) will automatically be discharged from our office. 

By signing below, I certify that I have read and agree to the foregoing and that I accept the terms.

Due to widespread abuse of controlled substances in our community, as well as increased DEA censorship of doctors' lack of monitoring of controlled substances, Arise Psychiatric Medical Group is implementing a strict controlled substance policy for all patients, effective immediately.

1. Controlled prescriptions include stimulants (ADHD medications such as Ritalin, Adderall, Concerta, Vyvanse) and benzo/hypnotics (Ativan, Xanax, Klonopin, Ambien, & Lunesta).
2. Arise Psychiatric Medical Group (APMG) will not refill controlled substances over the phone. It is your responsibility to ensure you have an appointment to see an APMG psychiatrist or nurse practitioner before you run out of the controlled substance.
3. APMG will not prescribe any controlled substance to you if you have not been seen in 90 days, for proper monitoring and safety.
4. APMG will not refill any controlled substances prescribed by another clinician even if you and that clinician have your own personal agreements.
5. If a controlled substance is sent to a pharmacy, APMG will not send duplicate copies of the same medication to another pharmacy. Please inform the APMG psychiatrist at the time of the appointment if you would like medication sent to a new pharmacy. Once the controlled substance is sent, APMG is unable to send the same prescription for a minimum of 30 days.
6. If you have found yourself over using or abusing controlled substances, or if you run out and experience withdrawal symptoms, please call the office and we will assist you the best way possible.

Albert Ma, MD Board Certified Adult Psychiatrist Board Certified Child & Adolescent Psychiatrist

Kingwai Lui, DO Board Certified Adult Psychiatrist Board Certified Child & Adolescent Psychiatrist

Setare Eslami, MD Board Certified Adult Psychiatrist

I verify that I have received this information and consent to the guidelines, as set forth by my physician.

FOR PATIENTS UNDER 18 YEARS OF AGE: I certify that I have legal guardianship of the patient and I am authorized to make healthcare decisions for the patient.

 

I hereby authorize Arise Psychiatric Medical Group to release all medical information to the above named insurance carrier(s) or to a designated attorney for the purpose of claims administration and evaluation, utilization review, and financial audit. This authorization remains valid and effective from the date of signing until revoked in writing.

I understand that I may request a copy of the authorization.

I read this authorization and understand it.

I hereby assign to Arise Psychiatric Medical Group all money to which I am entitled to for medical and/or surgical expenses relative to the services rendered by Arise Psychiatric Medical Group but not to extend my indebtedness to said physician and/or surgeon.

It is understood that any money received from the above named insurance companies over and above my indebtedness will be assessed to my account.

I understand I am financially responsible to Arise Psychiatric Medical Group for charges not covered by this agreement.

I further agree in the event of non-payment to bear the cost of collections and/or court costs and reasonable legal fees should this be required.

The following is a list of guidelines that will allow for efficient use of your time and that of the practice's time.

Please authorize the specific practices by initialing in the spaces provided and signing below.

Missed Appointment Agreement

Initials and a signature signifies an understanding and agreement to the following:

Due to the long wait list of patients needing to be seen, we have a strict appointment policy. When a patient does not show up to their scheduled appointment, or cancels too close to their scheduled time, we are unable to fill this appointment with another patient who desperately needs psychiatric services. Our strict appointment policy is our attempt to ensure our patients receive the care they need.

Patients will be discharged from Arise Psychiatric Medical Group if any of the following occurs:

CANCELLATIONS:

• 2 last minute cancellations
• 3 total cancellations (even if patient calls within the 24 hour window)

NO SHOWS:

• If the patient no shows to their initial evaluation
• 2 no shows

By signing below, I certify that I have read and agree to the foregoing and that I accept the terms.

I, the undersigned, agree to be in compliance with all medication management appointments and treatment plans with Arise Psychiatric Medical Group, Inc. I understand that my physician is requiring me to return as medically needed for these appointments (per their discretion.)

1. I will take my medication as prescribed by my doctor; I will talk with my doctor before changing dosage.
2. I will not accept the same prescriptions from any other doctors.
3. I will take care of my medications. My doctor will only replace lost, stolen or damaged prescriptions at his/her discretion, and I will be charged a $20 refill fee per medication.
4. My doctor will only approve early refills at his/her discretion, and I will be charged a $20 refill fee per medication.
5. My doctor will NOT approve refills when the doctor’s office is closed.
6. I will request all refills by calling my pharmacy and requesting that they fax the request to the facility during doctor’s office hours at least 3 to 5 days prior to taking my last dosage of medication.
7. I know that my doctor may change or stop my medication if it does not relieve my symptoms.
8. I understand that if I miss my scheduled appointment I MUST make a follow up appointment and my medications will only be refilled up to that date, and I will be charged a $20 refill fee per medication.
9. I understand that I will be required to be seen at least every 3 months to continue services.
10. I understand that if I have not been seen in 6 months or more, no refills will be given until I am seen by my provider.
11. I understand that if I have not been seen in over 1 year, no refills will be given until I re-establish care as a new patient and I am seen by my provider.

I understand that if this contract is broken at any time or if my physician feels that I am abusing any prescription medications, services with Arise Psychiatric Medical Group will be discontinued immediately and a referral to another facility will be given along with a final 30 day supply of medications.

*I agree to ALL of the above compliances within this contract with Arise Psychiatric Medical Group.

RELEASE OF HEALTH INFORMATION TO THE FOLLOWING INDIVIDUAL

USE AND DISCLOSURE OF HEALTH INFORMATION

I hereby authorize Arise Psychiatric Medical Group

RIGHTS

• I may inspect or obtain a copy of the health information that I am disclosing by signing this form.
• I have a right to receive a copy of this authorization.
• I may revoke this authorization at any time, but I must do so in writing and submit it to the following address:
              1500 Haggin Oaks Blvd Suite 202, Bakersfield, CA 93311
• Information disclosed pursuant to this authorization could be redisclosed by the recipient. Such redisclosure is in some cases not prohibited by California law and may no longer be protected by federal confidentiality law (HIPAA.) However, California law prohibits the person receiving my health information from making further disclosure of it unless another authorization for such disclosure is obtained from me or unless such disclosure is specifically required or permitted by law.