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 cancellation, late rescheduling, 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, cancel or reschedule less than 48 hours before the appointment time. Cancellation is by email to cancel@annarborpsych.mojohelpdesk.com or phone call to 734-707-1052.*

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 will never be charged if Ann Arbor Psych can find another patient to take my reserved time slot.*

I agree

Checking here is an electronic signature agreeing that a credit card is required on file and used for fees related to all subsequent/previous appointments and any other fees (such as no-show, late cancellation, late arrival, or paperwork fees)*

I agree

Charge may be taken at any time after appt and up to 36 hours before appointment. For example, if insurance reimburses 6 weeks later, the balance of the charge for services may then be applied to my card based on what insurance has reimbursed.*

I agree

Estimation of due amount is often taken day before appointment from card on file. For balances that come due between appointments (for instance when insurance gets back to us) an email is typically sent 1 week prior to date payment taken.*

I agree

Clinic attempts as courtesy to electronically verify benefits but it is ultimately my responsibility. Thus, if the insurance verification is inaccurate or coverage is denied, I am responsible for the cost of services rendered.*

I agree

BCBS PPO claims are submitted to BCBS of MI exclusively. In extremely rare cases, out-of-state BCBS PPO insurance may refuse to honor such a claim. In this case I understand I am responsible for the cost of services rendered.*

I agree

I understand changes to my insurance should be submitted via the link on the website at least 72 hours before an appointment otherwise my card may be charged the full price. (I will be refunded once insurance reimbursement comes in)*

I agree

Paperwork fees charged to patients are extremely rare because there is no charge if completed during appointment. Otherwise, paperwork completed between appointments incur $20 per page or $20 for an entire medication prior authorization.*

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. I will be held responsible for the cost of any appointment that insurance does not cover for any reason.*

I agree

I understand that I will sometimes receive protected health information via email and text message. I attest that my phone/email are 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

Checking here indicates I consent to treatment at Ann Arbor Psychiatry on an outpatient basis. I understand that there is no guarantee of improvement in symptoms.*

I agree

I understand that, if I undergo CAARS testing, I will incur a $50 psychometric testing fee, and genetic testing a $20 paperwork fee (which does not include other charges from the genetic testing company).*

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.*

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

I agree

If seeing a physician assistant: I understand that very rarely some BCBS or BCN insurances may require the patient see an MD or DO instead of PA which is discovered only if I call insurance and ask.*

I agree

I agree to call my insurance and verify my coverage with this clinic to assure coverage.*

I agree

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

I agree

Sign here