2025 New Patient Self Pay Good Faith Estimate Form

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-----What is your first name?* This field is required.
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-----What is your last name?* This field is required.
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-----What is your Date of Birth?* This field is required.
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At times correspondence is done via text message, phone call, or voicemail. Please type the phone number you would like to use:* This field is required.
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Our primary method of communication is email so that you have all questions answered in writing that you can refer to later. What email would like to use for correspondence?* This field is required.
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CONSENT TO THE USE OF EMAIL AND OTHER FORMS OF COMMUNICATION

Billing correspondence for the Medical Practice and its billing department and/or billing service provider is conducted using a HIPPA complaint encrypted email system. At times text and voicemail may also been used as a mean for communication. Billing correspondence can include PHI and the Patient understands that there are limitations to confidentiality when using electronic mediums for communication.

The Medical Provider, Medical Practice, and staff of the Medical Practice are the only ones have access to the secured e-mail account that is also password protected on two levels; password protected to log onto the laptop or mobile device and password to get into the email server. The servers that are used are not open to the public and are also password protected. If Patient chooses to use non-encrypted or some other non-secured server/network or allow others to have access to their apps or technology, then Patient will not hold, The Medical Provider, Medical Practice, and employees of the Medical Practice liable for any breach of PHI. Patient will also notify Medical Practice if their e- mail account has been compromised and when the situation has been resolved. Patient is responsible for any PHI that is located on their technology or e-mail.
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CONSENT TO THE USE OF EMAIL AND OTHER FORMS OF COMMUNICATION* This field is required.Your signature on this document indicates you authorize the Medical Practice, Morrison Clinic, and it's Billing Department known as CollaborateCOLLECT to contact you via e-mail,text, or phone and/or to respond to you via e-mail, text, or phone call, and that you understand that no form of electronically based communicationis a completely secure form of communication, and will therefore nothold liable the Medical Provider for any unintentional breach incommunication. You agree to release and hold harmless the Medical Practice and their Staff for any claim(s) you may have, past, presentand future, arising from the use of e- mail, text messaging, or voice mails. This consent will remain in force until you provide written revocation to the Medical Practice.
I agree
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Patient Signature* This field is required.
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In order to decrease the administrative burden for our low volume medical practice we require a working NON-debit credit card as a method of payment on each patient's billing account. This NON-debit credit card can be used as the primary method of payment or it can be put on file as a back up in the event that a debit or HSA card is declined due to low funds.* This field is required.
Please Select
Please Select
I understand a NON-debit credit card is required for all patient accounts.
This requirement does not work for me, I will submit the CollaborateCOLLECT form titled CollaborateCollect Billing Waiver so that I can see my clinician for one last appointment in order to obtain a referral to a new facility.
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Good Faith Estimate of Out of Network or Self Pay RatesDiagnosis Code: F99 Mental disorder, not otherwise specified Clinician: Amy Morrison NPI:1376508184 Location Morrison Clinic Virtual Tele-Psychiatry or 5300 Town and Country Blvd Suite 155 Frisco, TX 75034 Tax ID: 82-1157862 Summary of services: Psychiatric medical care which includes psychological testing done the week prior to appointments and occasionally the day of the medical appointment, medical appointments for medication management and treatment of a psychiatric illness, and at times the clinician may determine during the medical appointment that brief psychotherapy is also needed.
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The current self pay rate for the psychiatric evaluation is $408.41.* This field is required.
Yes, I elect to Self Pay at the rate for the psychiatric evaluation.
No, I will not be establishiing care with Morrison Clinic.
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The current self pay rate is $134.01for established patient medication management appointment. Psychological testing done the week prior to the appointment or as part of the lobby check are fully discounted to $0. On occasion your clinician may determine during your medical appointment that brief psychotherapy of at least 16 min in duration is needed. This would cost an additional $134.01 and if 38 minutes of psychotherapy occurs during your medical appointment it would cost an additional $175.53. Out of network or self pay rates increase on the 1st of January by 5%. Would you like to proceed with updating your payment type to Self Pay at Morrison Clinic?* This field is required.
Yes, I elect to Self Pay for thefollow up appointments. I agree to a rate increase of 5% each year on the 1st of January..
No, I will not be establishiing care with Morrison Clinic.
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The typical patient will need to be able to commit the time and money to be seen every 2 weeks for the first couple of months. Would you like to proceed with your new patient intake?
Yes, I can commit both the time to be seen every 2 weeks and the money to pay for these appointments at the current self pay rate.
No, I am unable to commit the time and/or money to be seen every 2 weeks and will pursue treatment elsewhere.
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Signature* This field is required.SELF PAY: CARDHOLDER SIGNATURE OF AGREEMENT : Your signature below attests that you read this agreement and understand that this estimation of out of pocket cost is based on current self pay rates which increase by 5% on the 1st of January each year. You authorize for any balance present on the patient's account to be charged to the credit card on file and you agree to pay in full for all services rendered. You authorize for the estimated out of pocket cost to be charged to the credit card on file the week prior to each appointment. You signature below attests that you can commit both the time to be seen every 2 weeks and the money to pay for these appointments at the current self pay rate.
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CONSENT TO THE USE OF EMAIL AND OTHER FORMS OF COMMUNICATION