Ann Arbor Psychiatry Patient Contract

What is your first name?*

What is your last name?*

Email Address?*

Date*

Date

If you are not the patient, what is the patient's name for whom you are agreeing to cover all charges incurred. (We will charge your credit card)

First NameLast Name

I understand that Ann Arbor Psych fees for a late cancel, missed appointment, or late arrival for an appointment are: $200 for an intake appointment, $100 for any medication management, $150 for any psychotherapy. *

I agree

I understand that I am charged the same fee as missing the appointment if I come very late or cancel less than 72 hours before the appointment time. Cancellation is by email to cancel@annarborpsych.mojohelpdesk.com.*

I agree

I understand that if the provider finds they do have a conflict of interest, they may cancel my appointment at any point in time, upon finding they have a conflict of interest. I understand that, by scheduling, I understand that the provider I have chosen to see does not have a conflict of interest, due to not seeing my parent/spouse/child/sibling/etc.

I Agree

I understand this is a very strictly applied policy, and applies even if the reason for missing is quite reasonable (sickness, family issues, etc).*

I agree

Checking here is a electronic signature indicating I understand that my credit cards are kept on file and used at any time for charging fees related to all subsequent appointments and any missed, late cancellation, late arrival, or paperwork fees. *

I agree

Charge may be taken at any time up (including up to 2 days before appointment). For example, if insurance reimburses 6 weeks later, the balance of the charge for services may then be applied to card based on what insurance has reimbursed.*

I agree

If I need to be invoiced prior to being charged (for charges over $50), I understand I should email billing@annarborpsych.mojohelpdesk.com. Missed appointments or late cancellations are not invoiced regardless. *

I agree

I understand that while clinic attempts to verify insurance benefits and send claims on my behalf, if insurance gives incorrect information or does not cover appointments for any other reason, I am responsible for appointment costs. While referrals are not generally required with our accepted insurances for mental health, I am responsible for acquiring any prior authorizations or referrals needed for care to reimbursed.*

I agree

Fees for paperwork are $20 per page (or more if complex). While not usually done, clinicians reserve right to charge at any time for time spent on case (reviewing history, communicating with family, documenting) between appointments at $20 per five minute increment*

I agree

I understand that I cannot see two different clinicians at Ann Arbor Psych on the same day and be covered for both appointments by insurance and will be held responsible for cost if insurance does not reimburse.*

I agree

I understand that, if not due to pharmacy or clinician error, for controlled substances (drugs that are marked as potential drugs of abuse by the DEA), there will be a $20 charge when prescribed BETWEEN appointments.*

I agree

I understand that ANY script written, between appointments, for a patient who has not been seen for 3 months will incur an additional $20 fee.*

I agree

I understand that I will sometimes receive protected health information via email and attest that my email address is secure and private. No one else can access my email and I log out of my email when not using or use only on secure devices. *

I agree

I understand that I cannot see two different clinicians at Ann Arbor Psych on the same day and be covered for both appointments by insurance and will be held responsible for cost if insurance does not reimburse.*

I agree

I understand that ANY script written, between appointments, for a patient who has not been seen for 3 months will incur an additional $20 fee.*

I agree

I understand that, if I undergo CAARS testing, I will incur a $50 psychometric testing fee, and genetic testing a $50 paperwork fee (which does not include other charges from the genetic testing company).

I Agree

I understand that email and text may sometimes be used to convey important information. My email address and phone number are reasonably secure.*

I agree

Checking these boxes indicates electronic signature that I have read and agreed to the policies above.*

I agree

Sign here

Clear