Office Policies

OFFICE POLICIES
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First NameLast Name
Date of Birth

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2 digit month, 2 digit day, 4 digit yearPatient's Date of Birth
Patients will be seen by appointment only. Same day appointments may be made in the event of an emergency. To schedule an appointment, call 405 400 1152.
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Our system will notify you (48 hours) ahead of your appointment and you are expected to notify us if you need to cancel. The no show/late cancellation (less than 24 hours notice) policy is strictly enforced. Two no shows/late cancellations in a 6 month period will result in discharge from our clinic.
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If you do not attend the visit and fail to give advance notice, a fee of $65 will be incurred
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If you are more than 15 minutes late for your appointment the visit will need to be rescheduled and a late cancellation charge will be applied.
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For in office visits, please arrive no later than 10 minutes prior to your appointment in order to complete the required forms and get properly checked in.
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For virtual visits, please complete the appointment check in form and any related questionnaires prior to your appointment time. Failure to check in by your appointment time may result in your appointment being canceled and considered a 'No Show'.
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Unless specifically discussed with your provider ahead of the visit, a guardian that is familiar with the patient's progress must be present for the duration of the appointment.
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Telemedicine visits should be conducted in a private place with adequate internet connection. Visits should not be conducted in moving vehicles or public places. *If the doctor deems it necessary to cancel your appointment after it has started because either of these criteria are not met, you may be charged a late cancellation fee.*
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After-Hours, Emergency, and Holiday Coverage
Our regular office hours are Monday-Friday 8am-5pm. If you are calling after-hours about a matter that does not necessitate immediate attention please leave a voicemail and we will return your call as soon as possible. However, if you are suicidal, fear that you will do harm to yourself or others, suspect you are having a severe allergic reaction to a medication, or face a life-threatening emergency, please call "911" or go the the nearest emergency room. You should instruct the emergency room to notify your provider. For the sake of continuity of care, we ask that you bring any discharge instructions or medication adjustments to your next appointment.
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Prescriptions and Refills
Prescriptions will not be refilled after hours or on weekends, so please plan accordingly. Refills will be processed within 2 business days.
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We reserve the right to decline issuing prescription refills if medications have been lost or stolen or if you have missed an appointment.
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A follow up appointment must be scheduled to receive a new medication refill.
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Evaluations for purposes other than treatment
We are a mental health treatment facility and our providers enter into a relationship patients for the purpose of offering treatment. As such, we do not do evaluations for the of determining eligibility for social security disability, fitness for duty, nor do we comment on matters concerning child custody.
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Non-evidence based treatments
We do not endorse or prescribe the use of medical marijuana or emotional support animals.
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Use and Disclosure of Health Information for Treatment and Payment
We may use or disclose health information in order to provide and coordinate your healthcare, or obtain payment for health services.

I, (Patient Signature or Legal Guardian if patient is a minor) First and Last Name, have reviewed, understand, and consent to the use and disclosure of health information for treatment and payment purposes. I also acknowledge that I have received a copy of the notice of privacy practices with the effective date of 01/2019.
Payment
Payment, including insurance copayments and deductibles, must be provided at the time of service.
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If you have an outstanding balance of $100.00 or more we will ask that a payment be made towards your balance before your next appointment.
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We do require a credit card on file for all commercially insured patients. Your card will never be charged without your knowledge and consent. (See credit card policy for more details)
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Please be aware that services provided may not be covered by your insurer, but you are responsible for payment of all services rendered. Any balance that remains outstanding for more than 90 days may be referred to a collections agency.
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Signature of Patient/Legal Guardian
Date

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2 digit month, 2 digit day, 4 digit yearDate
Printed Name
Relationship to Patient if applicable
Should be Empty:

OFFICE POLICIES

Prescriptions and Refills

Evaluations for purposes other than treatment

Non-evidence based treatments

Use and Disclosure of Health Information for Treatment and Payment

Payment