• NEW PATIENT CONTACT INFORMATION

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    If you have a life threatening emergency please dial 911 or go to the nearest emergency room. Some other possible sources of care are listed below.  

     

    YOU MUST HAVE AN ACTIVE PRIMARY CARE PHYSICIAN AND ACTIVE INSURANCE WHICH COVERS LAB SERVICES TO ESTABLISH WITH THIS OFFICE.  DO NOT COMPLETE THIS INTAKE IF YOU DO NOT. 

     

    ALSO, OUR RELATIONSHIP WITH MEDICARE IS LIKELY CHANGING IN THE NEXT SIX MONTHS.  WE WILL LIKELY BE CHANGING FROM A PARTICIPATING TO A NON-PARTICIPATING PROVIDER.

     

    WHAT DOES THIS MEAN?

     

    WE STILL ACCEPT MEDICARE PATIENTS. 

    BUT...PATIENTS ARE REQUIRED TO PAY IN FULL FOR THEIR VISITS...AND THEN BE REIMBURSED BY APPROPRIATE AMOUNT BY MEDICARE OR THEIR INSURANCE.

     

    FOR EXAMPLE:

     

    IF YOU WERE SEEN FOR A HIGH LEVEL VISIT (SEE FEE SCHEDULE FOR FULL DETAILS) YOU WOULD HAVE TO PAY SOMETHING CLOSE TO $194.79.  WE OR YOU WOULD THEN SUBMIT YOUR CLAIM TO YOUR INSURANCE AND THEY WOULD SEND YOU A CHECK FOR SOME PORTION OF THIS.  FOR STRAIGHT MEDICARE IT WOULD NORMALLY BE 50-80% OF THIS CHARGE.   BUT IT MIGHT TAKE SOME TIME TO GET PAID.

     

    SO...THIS IS PROBABLY NOT THE RIGHT OFFICE FOR YOU IF YOU CANNOT AFFORD THE UP FRONT PAYMENTS OR IF YOU HAVE DIFFICULTY NEGOTIATING WITH YOUR OWN INSURANCE COMPANY BECAUSE IF THERE IS A PROBLEM, YOU WILL MOST LIKELY HAVE TO DO MOST OF THE WORK WITH YOUR INSURANCE COMPANY.  

     

    We understand that some patients would like to get in quickly and want to notify you as soon as possible whether we will be able to assist you.  

       We will review this submission within the next three days.

       If you do not receive an email, voicemail or text within three days then, after review of submission, it has been determined that we are unable to assist you at this time.    You may resubmit this form in three months to see if we have greater availability or new resources to help. 

     

    YOU ARE STILL NOT CONSIDERED AN ACTIVE PATIENT OF THIS OFFICE UNTIL AFTER YOUR FIRST FACE-TO- FACE VISIT WITH DOCTOR GRACE WHEN BOTH OF YOU AGREE TO ENTER INTO A DOCTOR-PATIENT RELATIONSHIP.

            

  • We are IN-NETWORK with the following insurances and able to verify benefits the fastest.

    1. Medicare
    2. Aetna Insurance- [Majority of Policies IN-Network Including -Strategic Resource Company- [ Aetna Specialty Group Insurance]
    3. Cigna Insurance
    4. Cigna Great West
    5. Tri Care Humana Military Policies
    6. ChampVa-
    7. GEHA

     

    We are out-of-network with all other insurances and the verification of benefits can take considerable time, up to a month depending on the policy and current staff availability.

     

    In addition, the following plans generally have limited out-of-network benefits and end up being largely self-pay.  Keep in mind that psychiatric care tends to be very expensive (often several thousand dollars over the first months of treatment).   It is usually much more cost-effective to see a provider within your insurance.  

     

    1. BCBS Primary Insurance Policies [ All Policies]

    2. FHCP-Medicare Advantage Plans- Affiliate of BCBS

    3. Freedom, Insurance [ All Plans]

    4. Ultimate Insurance [ All Plans]

    5. Beacon Health Options [ All Pland]

    6. Magellan Health- [ All Plans]

    7. Optimum Healthcare

    8. WellCare Insurance

     

     

  • PLEASE ENTER DATE OF BIRTH OF PATIENT.  WE DO NOT SEE PATIENTS UNDER 18 YEARS OF AGE.  

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  • NOTE
    WE MAY NOT BE ABLE TO ACCEPT YOU AS A PATIENT. 


    THERE ARE MANY POSSIBLE REASONS FOR THIS:

    WE MAY NOT HAVE ENOUGH AVAILABILITY CURRENTLY TO ASSIST WITH THIS ISSUE.

    THERE MAY BE A CONFLICT OF INTEREST.  

    IT MAY BE OUTSIDE OUR EXPERTISE

     

    THIS NON-ACCEPTANCE MAY OCCUR AFTER THIS PAPERWORK, THE INITIAL PAPERWORK, OR INITIAL VISIT.  YOU ARE NOT A PATIENT OF THIS OFFICE UNTIL BOTH YOU AND DOCTOR GRACE AGREE TO ENTER INTO A DOCTOR-PATIENT RELATIONSHIP AFTER YOUR FIRST VISIT.

     

    We will review this information and reach out to you within three days. If you have not received an email or heard from a member of the staff within seven days then we are unable to accomdate you at this time...please try again in 3 months as we attempt to expand our services.

    Other options for care include the following:

     

     

     


    Suicide Prevention Lifeline Phone: 1-800-273-TALK (8255)

    Citrus County Lifestream Crisis Line: 866-355-9394

    Veteran Crisis Line:  1-800-273-8255. (Text 838255)

     

     

     

    Local Urgent Psychiatric Services

     


    The Vines Psychiatric Hospital

    24 hour Emergency care and Hospitalization

    866-671-3130

    https://thevineshospital.com/
    3130 Southwest 27th Ave. Ocala, FL 34471

     


    Springbrook Psychiatric Hospital

    24 hour Emergency care and Hospitalization

    352-600-3288

    springbrook hospital

    7007 Grove Road, Spring Hill, FL 

     


    Lifestream Behavioral Center

    Medication, therapy and 24 hour Emergency care and Hospitalization

    866-355-9394

    lifestream behavioral center

     

     

  • BY YOUR SIGNATURE BELOW YOU AGREE TO THE FOLLOWING:

     


    1.  I am NOT currently a danger to myself or others.  Emergencies should be dealt with by contacting 911 or presenting to the nearest emergency room.  The Vines in Ocala, Springbrook Hospital, Shands Hospital.  

     

    2.  I have insurance that allows me to receive labs and imagining and I have an active primary care physician that will assist in my care should medical needs arise.

    3.  I understand that Dr. Grace will likely be moving to a "NON-PARTICIPATING PROVIDER" with medicare in the near future and am willing to pay in full at time of service under the provisions marked above.  

    4.   THAT INFORMATION PROVIDED IS THE BEST TO MY KNOWLEDGE AND I NEED TO FOLLOW ALL INSTRUCTIONS TO OPTIMIZE MY HEALTH CARE FAILURE TO DO SO MAY RESULT IN INCREASE RISK OF SERIOUS ADVERSE EFFECTS.

     

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