Intake Form

I-View Intake Form

Thank you for your interest in I-View. We’re glad you’re looking into our therapy services and seeking the help you deserve.

Filling Out the Form

Please fill out the registration form below if you are interested in setting up a new appointment. We are unable to create any appointments if the form is not filled out. All information you provide to us will be kept confidential. 

Finding the Right Team Member

From there, a member of our team will evaluate how we can best assist you. They’ll determine which member of our team is the best fit for you and your needs. You should expect to hear from someone in our office within the next 24-72 hours in order to begin the process of setting up an appointment.

Getting What You Want Out of Therapy

Please remember that this form is not just for us. This form is mainly for you. We hope that by filling out this information, you can clarify what you want out of therapy, what you are struggling with, and how we can help.

 

We look forward to speaking with you soon.

Patient forms

Step 1 of 5

  • Patient Registration

  • Insurance Card

  • Additional Insurance Information

  • If no please complete the following
  • Credit Card Information

  • Credit Card Authorization

  • I, authorize 1-View Psychiatric NP & Behavioral Therapy PC, to charge my credit card for agreed upon service(s) and/or cancelation fee(s). I understand that my information will be saved to file for future transactions on my account.
  • AUTHORIZATION & CONSENT FOR PURPOSES OF TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS

  • I (print name)
  • consent to the use or disclosure of my protected health information by -View Psychiatric NP & Behavioral Therapy P.C. for the purpose of diagnosing or providing treatment to me or my minor child, obtaining payment for my health care bills or to conduct necessary health care operations at 1-View Psychiatric NP & Behavioral Therapy P.C.

    Notice as to Nature of Services: I understand that the care I receive at 1-View Psychiatric NP & Behavioral Therapy P.C. may be nontraditional or unconventional. Many of these services may not be recognized as standard medical practices, and may be considered investigational or experimental. Medications prescribed may be approved by the FDA for a different condition than that for which it is prescribed for me. I understand my doctor may request laboratory evaluation that may include venipuncture, analysis of stool, urine, saliva and breath.

    Notice that Services are not Primary Care: I understand that no physician or any other practitioner I see at 1-View Psychiatric NP & Behavioral Therapy P.C. is acting as my primary care physician unless otherwise agreed to by a physician in writing. As such, emergency services are not offered. I understand that even though my physician(s) and I-View Psychiatric NP & Behavioral Therapy P.C. practitioners may address issues affecting my general health, the practice is focused on psychiatric care and it is in my best interest to have a primary care physician to ensure that I am fully apprised of all available conventional means to address any medical conditions I may have. This is also important because services are exclusively office-based and are not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children. I also understand that it is my responsibility to inform 1-View Psychiatric NP & Behavioral Therapy P.C. who my primary care physician and specialists are, to let my physician know of any diagnoses I have received, and of any treatments I have had or am now undergoing for current conditions, and that I should keep my physicians and any practitioners I see informed on an ongoing basis. I also understand that it is very important to let my primary care physician know about any treatments performed at 1-View Psychiatric NP & Behavioral Therapy P.C. in order to properly and safely coordinate my care. My primary care physician is:

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  • Continued Care: It is paramount you adhere to your treatment plan in its entirety. Unfortunately, failure to meaningfully participate in your mental health treatment may constitute grounds for the termination of care. Grounds for termination may include any combination of adverse medication, visit and/or financial compliance along with aggressive, abusive or drug seeking behavior. 1-View Psychiatric NP & Behavioral Therapy P.C. observes a strict three Strike policy. In the unlikely event the termination of care is mandated, you will be given appropriate referrals and thirty (30) days notice.

  • Cancellation and/or No-Show Policy: 1-View Psychiatric NP & Behavioral Therapy P.C. urges you to keep every appointment, as treatment using psychiatric medications requires consistent monitoring. In the event you need to cancel an appointment, we require at least 24 hours notice, excluding Saturday and Sunday. Patients who cancel without proper notice or fail to show for a scheduled appointment will be subject to a $25.00 charge for each occurrence.

    Important Information Regarding Medication Refills: Refill requests must be received during business hours no less than one week prior to running out of medication. Refill requests are not addressed afterhours or on weekends. Medications cannot be refilled for those who have either missed or canceled their last appointment or have not been seen for two (2) months. Refills for controlled substances will not be issued outside of a regularly scheduled assessment.

  • Assignment of Benefits: I authorize direct remittance of payment of all insurance benefits, including Medicare, if I am a Medicare beneficiary, to 1-View Psychiatric NP & Behavioral Therapy P.C. for all covered medical services and supplies provided to me during all courses of treatment and care provided by 1-View Psychiatric NP & Behavioral Therapy P.C. and/or its affiliated entities or otherwise at its direction

  • I understand and agree this Assignment of Benefits will constitute a continuing authorization, maintained on file with I-View Psychiatric NP & Behavioral Therapy P.C, which will authorize and allow for direct payment to 1-View Psychiatric NP & Behavioral Therapy P.C. of all applicable and eligible insurance benefits for all subsequent and continuing treatment, services, supplies and/or care provided to me by 1-View Psychiatric NP & Behavioral Therapy P.C. If insurance payments are made directly to me, I will endorse such payments to 1-View Psychiatric NP & Behavioral Therapy P.C. within five (5) days of receipt of such payment.

    Financial/Insurance Responsibility for 1-View Psychiatric NP & Behavioral Therapy P.C. Services: I understand and agree to the following policies regarding financial and insurance responsibilities. Payment is required at or before each visit. I am responsible for charges incurred for all treatment rendered. This responsibility includes co-pay, co-insurance, deductible amounts, non-covered and excluded items not paid for by my insurance carrier or other party responsible for coverage of my medical expenses. I agree that I am responsible for any payments for services my insurance carrier determines, either now or at a later date, to be unreasonable or not medically necessary. I further understand, 1-View Psychiatric NP & Behavioral Therapy P.C. will not be obligated to take action on my behalf against an insurance carrier for collecting or negotiating my insurance claim. I also agree to be responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for 1-View Psychiatric NP & Behavioral Therapy P.C. to take action to secure payment of an outstanding balance owed.

    No Guarantees: I am aware that no practice of medicine is an exact science and acknowledge that there are and can be no guarantees as to accuracy or outcomes of any diagnosis or treatments that I receive at 1-View Psychiatric NP & Behavioral Therapy P.C.

    Revocation of Authorization: I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to 1-View Psychiatric NP & Behavioral Therapy P.C. Such revocation will not affect my financial responsibility to pay for services rendered by 1-View Psychiatric NP & Behavioral Therapy P.C. I understand that this revocation will not apply to information that has already been released in response to this authorization. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy.

    Patient Acknowledgment: I certify that the information I provide to my practitioners and my insurance company is correct. I certify that I am here to receive medical care and for no other purpose. I do not represent any third party. By signing and dating this form, I acknowledge that I have received a copy of this Authorization and Consent.

  • This field is for validation purposes and should be left unchanged.

Informed Consent for In-person Services during COVID-19 Public Health Crisis

  • This form contains important information about our decision (yours and mine) to resume in-person services in light of the COVID-19 public health crisis. Please read this carefully and let me know if you have any questions. When you sign this document, it will be an official agreement between us.

    Decision to Meet Face-to-Face
    We have agreed to meet in-person for some or all future sessions. If there is a resurgence of the pandemic or if other health concerns arise, however, I may require that we meet via telehealth. If you have concerns about meeting through telehealth, we will talk about it first and try to address any issues. You understand that, if I believe it is necessary, I may determine that we return to telehealth for everyone’s well-being.

    If you decide at any time that you would feel safer staying with, or returning to, telehealth services, I will respect that decision, as long as it is feasible and clinically appropriate. Reimbursement for telehealth services, however, is also determined by the insurance companies and applicable law, so that is an issue we may also need to discuss.

    Risks of Opting for In-Person Services
    You understand that by coming to the office, you are assuming the nsk of exposure to the coronavirus (or other public health risk). This nsk may increase if you travel by public transportation, cab, or ridesharing service.

    Your Responsibility to Minimize Your Exposure
    To obtain services in person, you agree to take certain precautions which will help keep everyone (you, me, our families, my other staff, and our patients) safer from exposure, sickness, and possible death. If you do not adhere to these safeguards, it may result in our starting/returning to a telehealth arrangement. Initial below to indicate that you understand and agree to these actions:
    • You will only keep your in-person appointment if you are symptom-free.
    • You will take your temperature before coming to each appointment. If it is elevated (100 Fahrenheit or more), or if you have other symptoms of the coronavirus, you agree to cancel the appointment or proceed using telehealth. If you wish to cancel for this reason, | won’t charge you our normal cancellation fee.
    • You will wait in your car or outside [or in a designated safer waiting area] until no earlier than 5 minutes before our appointment time.
    • You will wash your hands or use alcohol-based hand sanitizer when you enter the building.
    • You will adhere to the safe distancing precautions we have set up in the waiting room and testing/therapy room. For example, you won’t move chairs or sit where we have signs asking you not to sit.
    • You will wear a mask in all areas of the office (I[and my staff] will as well).
    • You will keep a distance of 6 feet and there will be no physical contact (e.g. no shaking hands) with me [or staff].
    • You will try not to touch your face or eyes with your hands. If you do, you will immediately wash or sanitize your hands.
    • If you are bringing your child, you will make sure that your child follows all of these sanitation and distancing protocols.
    • You will take steps between appointments to minimize your exposure to COVID-19.
    • If you have a job that exposes you to other people who are infected, you will immediately let me [and my staff] know.
    • If your commute or other responsibilities or activities put you in close contact with others (beyond your family), you will let me [and my staff] know.
    • If a resident of your home tests positive for the infection, you will immediately let me [and my staff] know and we will then [begin] resume treatment via telehealth.
    I may change the above precautions if additional local, state, or federal orders or guidelines are published. If that happens, we will talk about any necessary changes.
  • My Commitment to Minimize Exposure
    My Practice has taken steps to reduce the risk of spreading the coronavirus within the office and we have posted our efforts on our website and in the office. Please let me know if you have questions about these efforts.

    If You or I Are Sick
    You understand that I am committed to keeping you, me, [my staff], and all of our families safe from the spread of the virus. If you show up for an appointment and I [or my office staff] believe that you have a fever or other symptoms, or believe you have been exposed, I will have to require you to leave the office immediately. We can follow up with services by telehealth as appropriate.

    If I [or my staff] test positive for the coronavirus, I will notify you so that you can take appropriate precautions.

    Your confidentiality in the Case of Infection
    If you have tested positive for the coronavirus, I may be required to notify local health authorities that you have been in the office. If I have to report this, I will only provide the minimum information necessary for their data collection and will not go into any details about the reason(s) for our visits. By signing this form , you are agreeing that I may do so without an additional signed release.

    Informed Consent
    This agreement supplements the general informed consent/business agreement that we agreed to at the start of our work together.
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Notice of Private Policy

  • THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE FEEL FREE TO SPEAK TO YOUR DOCTOR, HIS/HER DESIGNEE, OR THE HIPAA PRIVACY OFFICER.
    I-View Psychiatric NP & Behavioral Therapy P.C. is committed to maintaining and protecting the confidentiality of your personal information. This Notice of Privacy Practices is being provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It will inform you about the ways in which we may use and disclose your health information, and the safeguards we have put into place to protect it. It also describes your rights and certain obligations we have regarding the use and disclosure of your health information.

    OUR DUTIES TO YOU REGARDING YOUR PROTECTED HEALTH INFORMATION
    “Protected Health Information” is individually identifiable health information expressed in the form of oral, written or electronic communications. This information includes demographic information such as your age, address, email address, and other information that relates to your past, present or future health condition and related healthcare services. I-View Psychiatric NP & Behavioral Therapy P.C. is required by law to:
    • Make sure your health information is kept private.
    • Give you this notice of our legal duties and privacy practices related to the use and disclosure of your protected health information.
    • Follow the terms of the notice currently in effect.
    • Communicate any changes in this notice to you.

    GOVERNMENTAL PRIVACY LAWS AND REGULATIONS
    There are several other federal, state and city privacy laws that provide stronger restrictions about the use and disclosure of health information. The stricter laws have been taken into consideration in developing our policies and this notice of how we will use and disclose your protected health information.

    HOW WE USE AND DISCLOSE YOUR HEALTH INFORMATION
    The following categories describe different ways that we use and disclose your health information. We will not use your confidential information or disclose it to others without your authorization, except for the following purposes:

    Treatment. We may use and/or disclose your confidential health information to provide you with treatment and/or services. This includes your doctor’s recommendation(s), and those of other professionals/paraprofessionals including clerical, coordination and management staff.

    Payment. Your protected health information will be used, as needed, to bill and collect payment for treatment and services provided to you. We may share information about a treatment and/or service you may receive to your health insurer to receive approval for payment.

    Health Care Operations. We may use and disclose health information about you for regular health care operations. The medical staff in this practice will use your health information to assess the care you received and the outcome of your case compared to others like it. Your information may be reviewed for risk management or quality assessment/improvement purposes in our efforts to continually improve the quality and effectiveness of the care and services we provide.

    We will share your protected health information with third-party “business associates” who perform various activities for the practice. The business associates will also be required to protect your health information.

    We may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning your identity.

    Appointment Reminders. We may use and disclose health information to contact you as a reminder that you have an appointment for treatment or care in our Practice. These reminder will not identify the purpose of your visit.

    Required by Law. We will disclose health information about you when required to do so by feder, state, or local laws.

    Public Health Activities. We may disclose your confidential health information for the following public health activities and purposes:
    • To report health information to public health authorities that are authorized by law to receive such information for the purpose of preventing or controlling disease, injury or disability;
    • To report child abuse or neglect to a government authority that is authorized by law to receive such reports;
    • To report information about a product or activity that is regulated by the US Food and Drug Administration (FDA) to a person responsible for the quality, safety, or effectiveness of the product or activity;
    • To conduct post-marketing surveillance, as required; and To alert a person who may have been exposed to a communicable disease, if we are authorized by law to give this notice.

    Legal Proceedings. We may release protected health information about you in response to a court or administrative order if you are involved in a lawsuit or dispute. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful processes by someone else involved in the dispute, but only if efforts have been made to tell you about the request.

    Law Enforcement. We may release health information if asked to do so by law enforcement officials:
    • In response to a court order, subpoena, warrant, summons or similar process.
    • To identify or locate a suspect, fugitive, material witness or missing person.
    • About the victim of a crime if, under certain circumstances, we are unable to obtain the person’s agreement.
    • About the death we believe may be the result of criminal conduct.
    • About criminal conduct at the Practice.
    • In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

    Research. Under certain circumstances, we may use and disclose your confidential information for research purposes without authorization. An authorization would not be necessary if your identifying information was removed.

    Workers’ Compensation. We may release your health information to comply with Workers’ Compensation Laws and other similar legally-established programs. The programs provide benefits for work-related illness or injury.

    Promotional Gifts. We may use your confidential health information so that we may provide you with nominal gifts. We will not disclose your confidential information to other companies for their marketing purposes.

    Health Related Benefits and Services. We may use and disclose health information to inform you about health-related benefits or services that may be of interest to you. You may be contacted by the Practice regarding general health-related products and services and/or health-related products and services targeted to your specific health status or condition, but only where we believe those products or services may benefit you. If the communication is targeted to you, it must explain why you were targeted and how the product or service relates to your health. Any communication you receive must identify the Practice as the source of the communication, inform you if we received any payment for making the communication, and contain instructions about how you may request that we not contact you further about such health-related products and services.

    Criminal Activity. Under certain Federal and State laws, we may disclose your protected health information if we believe that its use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose your health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

    Government Functions. We may disclose your health information to the U.S. Military or to authorized federal or state officials for purposes specified by federal law. Coroners, Funeral Directors, and Organ Donation. We may disclose your health information to a coroner or medical examiner. This may be necessary to identify a deceased person or to determine the cause of death. We may also disclose protected health information to funeral directors as authorized by law to assist them in carrying out their duties. Protected health information may also be used and disclosed for organ, eye, and tissue donations if you have previously agreed to organ donation.

    Parental Access. Various New York State laws determine what protected health information can be disclosed to parents, guardians, and persons acting in a similar legal status. We will act consistently with the law and will make disclosures only when necessary.

    Individuals Involved in your Care. Unless you object, we may use or disclose your health information to notify or assist in the notification of a family member or personal representative of your location, your general condition, or death. If you are present, you will have the opportunity to object to this type of use or disclosure. If you are unable to decide or if it is an emergency, we may disclose information that is directly relevant to the person’s involvement in your healthcare, if we determine that it is in your best interest to do so.

    YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
    Although your health record is the physical property of I-View Psychiatric NP & Behavioral Therapy P.C, the information belongs to you. You have the following rights regarding your protected health information. You may make any of the following requests by completing a “HIPAA Patient Rights Request Form” or by submitting a written request to our office.

    Right to Inspect and Copy. You have the right to both inspect and obtain a copy of your protected health information that is contained in a “designated record set” for as long as we maintain your health information. This information is used to make health-related decisions about your care and typically includes professional treatment/progress notes, supplement programs, laboratory reports, prescriptions, and billing/financial records. This request does not include inspection and copying of the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to laws that prohibit access. If you request copies, we may charge you the copying and mailing costs. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to health information, you may request that the denial be reviewed.

    Right to Request Restrictions.  You have the right to request a restriction or limitation on the health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose about you to someone who is involved in your care or the payment for your care. While we consider all requests for restrictions carefully, we are not required to agree to your request.

    Right to Request Amendment. If you believe the health information we have about you is incorrect or incomplete, you may ask us to amend the information. You have a right to request an amendment for as long as the information is kept by or for I- View Psychiatric NP & Behavioral Therapy P.C. if we determine the record is inaccurate. We may deny your request if it is not in the appropriate form or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:
    • Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
    • Is not part of the information kept by or for I-View Psychiatric NP & Behavioral Therapy P.C.
    • Is not part of the information which you would be permitted to inspect or copy.
    • Is not accurate and complete.

    Right to Request Confidential Communications. You may request that we communicate with you using alternative means or at an alternative location. You may also ask that we mail information to you in a sealed envelope rather than a postcard. While we will consider this request carefully, we are not required to agree to all requests.

    Right to Request and Accounting of Disclosures. You have the right to an accounting of disclosures. This is a list of where we have sent your protected health information that does not include disclosures made for treatment, payment, or healthcare operations as described in this notice. Your request must state a time period beginning on or after April 14, 2003, and no more than 6 years from the date of request.

    Right to Obtain a Copy of this Notice. You have the right to a paper copy of this notice. You may request a copy of this notice at any time. To obtain a copy of this, please contact the HIPAA Privacy Officer for his/her designee.

    CHANGES TO THIS NOTICE
    We reserve the right to change our privacy practices and this notice. We reserve the right to make changed notice effective for health information we already have about you as well as any information we receive in the future. If we change the notice, we will provide each active patient with a new notice. You may also obtain a new notice by calling our office.

    COMPLAINTS
    If you believe your privacy rights have been violated, you may file a complaint with I- View Psychiatric NP & Behavioral Therapy P.C. 's Privacy Officer or his/her designee at the address below. No retaliation will occur against you for filing a complaint. All complaints must be submitted in writing. You may also file written complaints with the Secretary of the US Department of Health and Human Services. Please call our office to obtain the correct address for the Secretary.

    I-View Psychiatric NP & Behavioral Therapy P.C.
    HIPAA Privacy Officer
    124 Northern Lights Drive
    Syracuse, NY 13212


    OTHER USES OF YOUR HEALTH INFORMATION
    Other uses and disclosures of your health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written authorization. We are unable to take back any disclosures we have already made with your permission and we are required to maintain in our records the care that we provided to you.

    This notice was published on 04/08/2019 and all provisions became effective by Federal Law on April 14, 2003. Our notice of Privacy Practices remains in effect until modified by I- View Psychiatric NP & Behavioral Therapy P.C.
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Patient Responsibility Policies

  • Forms Policy:
    The only documentation regarding your health or illness, required by law (and included in the office visit charge) is an office visit note. Completing paperwork for schools, camps, the Family Medical Leave Act (FMLA) claims, long-term care, life insurance, the Department of Veterans' Affairs, disability claims or other purposes is unnecessary duplication and goes beyond routine medical care. Therefore, it cannot be billed to your insurance company. Since all forms require our signature, we are personally responsible for the accuracy of the information provided. Incomplete or inaccurate information may have far reaching consequences for your case. Filling out forms thus requires careful consideration and a considerable amount of our time. Therefore, it is our office policy to charge for the completion of any form as follows:

    -Processing and completion fee of $25 per from
    -$15 per letter

    We cap the charge at $50 maximum per form. We will complete the form and fax it to the designated recipient (or return it to you if that is what you prefer) within 2 business days of the receipt of payment.

    Finally, Completion of certain forms such as, school forms, camp forms, sport participation forms, disability determination, etc. may require an update of your medical information or a special examination. In such cases, you will be asked to make an appointment.

    COPAY POLICY:
    Our office does not bill out of network (non-contracted) insurance plans. If your plan is out of network, you are required to pay in full for your visit at the time services are rendered. We will bill most in-network primary insurance companies. In order for us to bill your insurance, you must provide us with a current copy of your medical insurance card at every visit. If you are unable to provide this at the time of your appointment, you may reschedule or pay in full at the time of service. While providing this service, please remember that your insurance company requires you to know your plan’s benefit policies including co-payments, the specifics of what your policy covers, and to notify us when your insurance plan changes, prior to your appointment. Each plan has its own stipulations regarding the coverage of, and payment for, medical services; therefore, it is extremely difficult for us to be aware of the multitude of individual requirements for each of our patients’ plans. If your insurance does not respond to or pay your claim, the full balance will become the patient/guarantor’s responsibility. Partial payments will not be accepted unless prior payment arrangements, appropriately based on balance due, have been made. If your insurance is out of network, you must pay for your services in full at the time of your visit. Your co-payment is due at the time of check-in. I|-View Psychiatric NP and Behavioral Therapy P.C. reserves the right to reschedule and/or cancel your appointment if co-payment is not paid at time of service.

    Missed Appointment Policy:
    You must call 315-391-7770 by 2:00 p.m. on the day prior to your scheduled appointment to notify us of any changes or cancellations. To cancel or change a Monday appointment, please call our office by 2:00 p.m. on Friday. If prior notification is not given, it will be considered a missed appointment. After the first missed appointment, the parent/guardian or client will be notified by letter of our office policy and a $30 fee will be charged. IF YOU ARE MISSING AN INTAKE APPOINTMENT (first appointment with our office) THERE WILL BE A $50 CHARGE BEFORE WE CAN GIVE YOU ANOTHER APPOINTMENT. The appointment may be rescheduled once the fee is paid. After a third scheduled appointment is missed, it will be necessary to terminate our professional relationship with the client and/or family. We will be available to treat a child (under the age of 18) client for 30 days after termination on an urgent basis only, so that he or she will have access to care while the family/guardian chooses another Provider. We will provide you with 3 refills on medications except controlled substances. We will also provide 3 referral sources along with the official discharge letter. You may be prevented from scheduling future appointments for a period of 6 months from the time of the third missed appointment and may be seen on a worked-in basis only, depending on availability.

    Therapy Policy:
    To provide our patients with the best possible care, we now require that those receiving medication management participates in therapy at least once a month. If the requirements are not met, you will be pending discharge. We have instilled this policy to help our patients maintain the best therapeutic care.

    Past Due Balances Policy:
    Balances over 90 days past due will need to be paid before we can schedule another appointment. If the balance is not paid, you may be pending discharge.

    Appointment Confirmation Policy:
    Our office calls the day before your scheduled appointment. If you miss the call, it is your responsibility to call back and confirm. Unconfirmed appointments will be given to another patient that is on our waiting list.

    By signing this form, you are stating that you understand and agree to the policies set by our office as stated above.
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