Financial Policies and Benefit Assignment

I authorize Georgia Psychiatry and Sleep to furnish information as necessary to my insurance carrier regarding my illness and treatment, and I assign to Georgia Psychiatry and Sleep all insurance payments for medical services rendered. I understand that I am responsible for providing all necessary information to the office or submitting charges to the insurance company for payment. If I fail to provide this information, I accept the financial responsibility of payment for services rendered. This office has a cancellation policy that requires 24-hour advance notification. I understand that if I cancel with less than 24-hour notice, a charge will be made for the time reserved. This charge is not covered by insurance and is not payable from any insurance company.

Consent to Treatment with Psychotropic Medications

The indications for the medication(s) that are a part of my treatment plan have been discussed with me. I understand that, on occasion, some psychotropic medications may be used for psychiatric conditions or symptoms, despite a lack of FDA approval for these uses. I accept this and accept the advantages and disadvantages of this treatment. Based on the information provided, I agree to comply with the instructions provided by my physician.

If I have further questions or concerns about the medication(s) or treatment, I understand that I should contact the prescribing physician as soon as possible.

Drug Screen Policy

At the initial evaluation and from time to time during treatment, patients may be asked to submit a urine specimen for analysis for drugs. The results of these look to see if in fact the patient is taking medications prescribed and also to verify that the patient is not using other unauthorized substances. For the wellbeing and health of our patients, the screening will also help to determine there are no dangerous interactions between multiple drugs.

The fee is normally covered by insurance, but there may be a copay or balance owed after the insurance pays. It is the responsibility of the patient to take care of these fees owed. If you do not have insurance or your insurance does not cover it, we will collect $15 as a charge for this urine drug screen test. 

By your signature below, you indicate that you have read, understand, and agree with this policy. This document will be scanned into your permanent medical records and you may request a copy of it for your own files. 

Consent to Treatment with Telemedicine

By signing this form, you agree that you have read, understand, and agree with these terms if scheduled for a telemedicine appointment. By signing below, I acknowledge the following:

I am aware of the provider that I am scheduled to have my telemedicine appointment with. 

I have been able to ask questions about telemedicine sessions with GPS staff.

I am aware that I can reach out to the office if I have any questions.

I understand that no guarantees have been made about the success or outcome, and I agree to take part in a telemedicine appointment.

I understand that the telemedicine consultation will be similar to a routine medical office visit.

I understand that this is an option on a temporary basis due to the COVID-19 Pandemic.

Click here to access patients' rights and responsibilities.

Financial Policies and Benefit Assignment

I authorize Georgia Psychiatry and Sleep to furnish information as necessary to my insurance carrier regarding my illness and treatment, and I assign to Georgia Psychiatry and Sleep all insurance payments for medical services rendered. I understand that I am responsible for providing all necessary information to the office or submitting charges to the insurance company for payment. If I fail to provide this information, I accept the financial responsibility of payment for services rendered. This office has a cancellation policy that requires 24-hour advance notification. I understand that if I cancel with less than 24-hour notice, a charge will be made for the time reserved. This charge is not covered by insurance and is not payable from any insurance company.

Consent to Treatment with Psychotropic Medications

The indications for the medication(s) that are a part of my treatment plan have been discussed with me. I understand that, on occasion, some psychotropic medications may be used for psychiatric conditions or symptoms, despite a lack of FDA approval for these uses. I accept this and accept the advantages and disadvantages of this treatment. Based on the information provided, I agree to comply with the instructions provided by my physician.

If I have further questions or concerns about the medication(s) or treatment, I understand that I should contact the prescribing physician as soon as possible.

Consent to Treatment with Telemedicine

By signing this form, you agree that you have read, understand, and agree with these terms if scheduled for a telemedicine appointment. By signing below, I acknowledge the following:

I am aware of the provider that I am scheduled to have my telemedicine appointment with. 

I have been able to ask questions about telemedicine sessions with GPS staff.

I am aware that I can reach out to the office if I have any questions.

I understand that no guarantees have been made about the success or outcome, and I agree to take part in a telemedicine appointment.

I understand that the telemedicine consultation will be similar to a routine medical office visit.

I understand that this is an option on a temporary basis due to the COVID-19 Pandemic.

Drug Screen Policy

At the initial evaluation and from time to time during treatment, patients may be asked to submit a urine specimen for analysis for drugs. The results of these look to see if in fact the patient is taking medications prescribed and also to verify that the patient is not using other unauthorized substances. For the wellbeing and health of our patients, the screening will also help to determine there are no dangerous interactions between multiple drugs.

The fee is normally covered by insurance, but there may be a copay or balance owed after the insurance pays. It is the responsibility of the patient to take care of these fees owed. If you do not have insurance or your insurance does not cover it, we will collect $15 as a charge for this urine drug screen test. 

By your signature below, you indicate that you have read, understand, and agree with this policy. This document will be scanned into your permanent medical records and you may request a copy of it for your own files. 

Please click here to access patients' rights and responsibilities.