Cash-paying patient rates outside of insurance:
15 min $105
30 min $210
45 min $315
60 min $420
Other Charges (for ALL patients, including insurance, cash-paying, and Medicare)
Appointment requirements and REFILLS: (EXTREMELY IMPORTANT, PLEASE READ!!!!!!!)
Beginning December 1, all patients must have a follow up appointment with the psychiatrist or nurse practitioner every 90 days.
Patients will be provided 3 months worth of prescriptions at the time of appointmennt (if a controlled substance, they will be written electronically for the next to months to be on file with the pharmacy).
Outside of appointments, each refill request will be 25 DOLLARS per medication. IT IS BEST THEREFORE TO MAKE SURE YOUR APPOINTMENT IS SCHEDULED.
There will be one month grace on refills, but the fill will be for just one month, and . the patient must make an appointment at the time of fill.
PAPERWORK (FORMS OR LETTERS REQUESTED)-WILL ONLY BE DONE OUTSIDE OF APPOINTMENTS
Charged by Time:
Up to 10 minutes: 70 dollars
Up to 20 minutes: 140 dollars
Up to 30 minutes: 210 dollars
Up to 40 minutes: 280 dollars
PHONE CALLS:
WILL BE TREATED AND CHARGED AS TELEPSYCH APPTS OF 15 or 30 MINUTES. THESE ARE NOT BILLABLE TO MOST INSURANCES, AND THUS WILL BE CHARGED AS CASH TO THE PATIENT AT THE APPOINTMENT RATES:
15 min $105
30 min $210
45 min $315
60 min $420
BALANCES
ALL BALANCES OVER 75 DOLLARS MUST BE PAID IN FULL USING THE ACTIVE CREDIT CARD ON FILE BEFORE ANY APPOINTMENT IS MADE OR REFILLS ARE PROVIDED.
IT IS THE OBLIGATION OF THE PATIENT OR GUARDIAN TO UPDATE CREDIT CARD NUMBERS, CONTACT INFORMATION AND INSURANCE INFORMATION IN THE EVENT OF ANY CHANGES.
ANY BALANCE OVER 300 DOLLARS UNPAID FOR 90 DAYS MEANS IMMEDIATE DISMISSAL FROM PRACTICE, WITH 30 DAYS OF EMERGENCY CARE UPON NOTIFICATION TO THE CLIENT.
CHANGE/CANCEL//NO SHOW POLICY
WE HAVE MODIFIED THESE, PLEASE NOTE THE CHANGES!!!
ANY CANCELLATION WITHIN 24 HOURS WILL BE CHARGED A FEE OF 105 DOLLARS (THIS IS REDUCED FROM A 48 HOUR REQUIREMENT AND A 140 DOLLAR CHARGE). THIS IS FOR ANY APPOINTMENT WITH ANY PRACTITIONER.
WE WILL CHARGE REGARDLESS OF REASON, INCLUDING ILLNESS.
LATE SHOW POLICY
IF THERE IS ANY TIME LEFT IN THE APPOINTMENT, OUR OFFICE WILL TRY OUR BEST TO ACCOMODATE YOU TO GET YOU THE COMPLETE APPOITNMENT TIME, BUT THERE IS NO GUARANTEE THIS WILL BE POSSIBLE ESPECIALLY CONSIDERING OUT BUSY SCHEDULE.
THE PATIENT WILL BE ABLE TO UTILIZE THE TIME LEFT, AND THE PATIENT CAN OF COURSE REQUEST ANOTHER APPT TO COMPLETE THE APPOINTMENT TREATMENT.
ON-TIME MATTERS :)
We (especially Dr. Rosen) are fully aware of on time matters. We are actively engaged at this time to create a markedly improved on-time performance, which requires cooperation not only from him, but also from all our clients. The appointments will be targeted to end just before the end of the appointment period so that we can start the next appointment promptly.
Should there be an extremely urgent/important matter, please inform the office manager on arrival and/or Dr. Rosen at the very start of the appointment so we can coordinate care and ensure we stay on schedule. If needed, the appointment may need to be continued at the end of the day or the following morning.
TELEPSYCH APPOINTMENTS INTERNET POLICY:
The patient must be in a stable place, on the computer or an iPad, and NOT on a phone.
The patient must have good, consistent wifi, and should confirm they have a good connection at the start of the appointment.
The patient should be on Chrome or Firefox only. Safari and Explorer are not compatible with our system.
MINORS:
ALL MINORS MUST HAVE A PARENT ACCOMPANY THEM AT THE APPT OR BE AVAILABLE ON PHONE AT TIME OF THE APPOINTMENT.
As a courtesy, we have Implemented an email reminder system for your appointments. Please note, if you have indicated that you would like to receive appointment reminders by email, these reminders are simply a courtesy; it is your responsibility to remember your appointment time. The missed appointment charge will not be waived If you do not receive a reminder.
INSURANCE AND APPOINTMENT FEES:
As physicians and therapists, our relationship is with you, not your insurance company. As a courtesy to you, we will send our bill to your insurance company If you are covered under an Insurer with whom we participate. All charges are the client's responsibility from the time services are rendered,
It is you the client's responsibility to contact their insurance company and ensure that our practice participates in your plan. It Is also the client's responsibility to understand your coverage and benefits, including deductible amounts, pre-certifications, referral, and authorization requirements.
The practice is not responsible for knowing the requirements of your specific plan. We will try to assist you to ensure that all plan requirements are met, but you are responsible to ensure coverage. Please be aware that some, and possibly all, of the services you receive may not be covered by your insurance company. You are financially responsible for any services provided by our office regardless of whether those services are covered by your insurance plan. Please also note that that certain Insurances will not cover services for two providers at one location on the same day (i.e. a patient may not be allowed to see both their therapist and psychiatrist on the same day).
You are responsible to notify us of any insurance changes before your next appointment.
INSURANCE RESPONSIBILITY:
Any Insurance claim that has not been covered/paid (denied for any reason) by your insurance plan becomes YOUR responsibility to pay 90 days after our proper initial filing of the claim. We will promptly re-file the claim should there be any errors on our part noted as cause of denial. Any payment due must be made before your next appointment. Additionally, you must pay any claim that Is denied due to your Insurance being Inactive at the time of services, or due to failure on the part of the patient or responsible party to obtain prior authorization or referral and/or complete the forms required by the insurance company to process the claim, before your next appointment. All delinquent balances must be paid In full before any further services will be provided.
PATIENT RESPONSIBILITY:
The unpaid patient responsibility balance is due no later than 60 days after the date of service. Patient responsibility includes, but Is not limited to, co pays, deductibles, co-insurance, and fee for service. As a courtesy, statements are automatically sent to those with an unpaid patient responsibility balance monthly. Any balance that is past this date Is deemed delinquent, and you agree that we may charge the credit card on file with us for this balance. All delinquent balances must be paid in full before any further services will be provided. Failure to pay a balance will result in collection actions and you may be discharged from the practice. If a patient's balance Is turned over to a collection agency, an additional 25% of the balance wiII be added to the account. Patients/Guardians/Responsible Parties are responsible for notifying our office of any changes to address or other contact Information.
If we are not a participating provider with your health Insurance, we do NOT send bills for out-of-network benefits to other Insurers. We will gladly furnish a statement for you to provide to your insurance company to obtain reimbursement. It Is your responsibility to file with your insurance company. We will require payment before the time services are rendered, and reimbursement will be provided to you directly from your insurance company.
PAYMENTS:
Payments can be made by personal check, certified check, credit, or debit card. For the safety of our staff, we do not accept cash.
Please be advised that each bounced check occurrence will incur a $60 fee.
MEDICATIONS:
It Is our policy to give a maximum of 90 days of medication at the time of your appointment (Including refills). In many cases, a much shorter period is appropriate and necessary. It is your responsibility to remain current with needed appointments so that there Is no lapse In medication. You must be seen in the office a minimum of once every 90 days unless agreed upon with the provider. If you fail to meet this requirement, you will be considered "Inactive" and discharged from the practice with no further medication prescribed. Readmission to the practice will require a new initial" appointment. If you are discharged you will recieve 30 days of emergency care.
REFILLS:
Medication refills between appointments are at our discretion. For your health/safety and the highest care possible, please note that these "inter-appointment" refills are a rare exception. If refills are needed between appointments, we require 72 hours advance notice. At our discretion, we will provide up to one month's supply of medication. We expect you to be seen in the office before using up the "inter-appointment" refill.
There Is a $25.00 fee per medication for providing refills outside of appointments. You are required to remain compliant with our appointment requirements to ensure no lapse in medication. We reserve the right to refuse refilling any medication if we believe it is clinically necessary to evaluate you before prescribing medication.
Please note, we do not respond to pharmacy requests for refills as they are frequently inaccurate and often automated.
PRIOR AUTHORIZATION:
Should you find that your insurance requires prior authorization for a prescribed medication, please note that this process may take up to 7 business days. Prior authorizations require a significant Investment of our time, and therefore there is a $25 fee for completion. Prior authorizations are typically required on an annual basis by your insurance company. Please check with your insurance company or pharmacy for the results of prior authorizations. Often, your pharmacy will be notified of the result and communicate that to you.
HOW TO CONTACT US:
EMERGENCIES AND URGENT MATTERS:
In the event ot an emergency (Immediate attention is required for oneself or another due to a life-threatening situation or a potential threat to safety), call 911 or go to the nearest hospital emergency room.
If you have an urgent matter and need to contact us, you may call the office directly at (404) 450-0338 (Mon-Fri 9am-5pm). We will promptly return a phone call for any urgent matter (such as a significant side effect of (such as a significant side effect of medication). If an urgent matter arises after those hours, you may contact us via our automated answering service or via the OhMD app (see below).
ROUTINE PHONE CALLS:
Any non-urgent matters, such as the routine need for medication changes in dose or formulation, therapeutic issues, or any other non-urgent concern should be addressed during appointment times or using the OhMD app or through the Patient Fusion Portal (see below). In the rare event that a non-urgent matter requires a phone call to our office, please call (404) 450-0338 (Mon-Thurs 9am-Spm) our front office staff will return your call as soon as possible.
OhMD:
For your convenience, you can use the "OhMD" app (available on I-phone and android) as an optional means of communication with us. This app is HIIPA compliant.
PATIENT FUSION:
For your convenience, you can enroll in the online portal "Patient Fusion” as an optional means of communication with us. This Portal Is HIIPA compliant.
RECORD REQUESTS:
Should you need a copy of your medical records to be sent to another physician, therapist, or any other provider, this may take up to 10 business days to complete. The fee to compile and send these records are as follows: $25 administrative fee plus $.50 per page.
TERMINATION OF SERVICES:
Any patient who has not been seen by us nor contacted our office regarding an upcoming appointment for more than 365 days will be considered no longer under our care and will be discharged from the practice. These patients may call us again at any time to schedule a new Intake appointment. Additionally, there are other reasons for permanent termination of services including but not limited to non-payment of fees, three or more missed appointments, abusive behavior toward staff, abuse/misuse of prescribed medication. If termination becomes necessary, you will be provided referrals for alternate care. Emergency care will be provided for you for 30 days.
MICHAEL ROSEN, M.D.
11755 Pointe Place, A-1 Roswell, GA 30076
&
1120 Coggins Place
Marietta, GA 30060
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your medical records are confidential and protected by state and federal laws Including the federal Health Insurance Portablllty and Accountability Act (HIPAA). Protected health Information is Information about your health record that may Identify you.
Uses and Disclosures of Protected Health Information:
Treatment: We may use or disclose your health information to provide, coordinate and or manage your health care services and treatment. We may disclose your health information to other healthcare professionals, such as therapists, doctors and/or nurses who also provide services to you to ensure proper coordination of care. All employees of Michael Rosen, M.D., are required to sign a workplace confldentlality agreement, and agree to access only the mlnlmally necessary healthcare Information In carrying out their primary Job function.
Payment: We may use or disclose your health Information to bill and collect payment for the services that we provide to you. This may involve office staff, health Insurance organizations, or other businesses that may become involved In helping to collect unpaid balances.
Health care Operations: We may use and disclose information about you for health care operations. These operations Include, but are not limited to, quality assessment, cost management, employee review, and business planning activities. We may use or dlsclose medical Information about you to remind you of an upcoming appointment, to check on you after you have received treatment, to obtain prior authorization for a treatment, etc. We may disclose your Information to contractors (business associates) who provide
certain services to us. Privacy and confidentiality Is very Important during the treatment of children and adQlescents. Many parents/caretakers want to know what transpired In psychotherapy sessions with children/ adolescents. However, some degree of confldentlallty Is essential In order to develop a
therapeutic alllance (particularly with adolescents). This alliance subsequently Improves the quality of their psychiatric care. Therefore, our providers will use their clinical Judgment In deciding whether and when to relay Information to parents that has been revealed to cllnlclans by patients. In most cases, If It Is felt that Information needs to be communicated to parents, patients will be encouraged to communicate this Information themselves. In cllnlcally urgent or emergent situations, we wlll llkely relay the·tnformatlon to parents directly.
1) Serious threat to health or safety- If we determine that you present a serious danger or threat to yourself or another, we may disclose Information to provide protection for you or the Intended victim.
2) Abuse/ Neglect- We will report to the appropriate authorities any circumstances of child abuse or neglect, elder abuse or neglect, or abuse or neglect directed towards a disabled person.
3) Legal proceedings. We may disclose protected health Information If required to do so by law I.e. court order, subpoena, etc. Our providers also reserve the right to use and disclose Information about you If doing so Is necessary to defend our providers from any legal action brought against our providers In relation to your care.
4) Public Health Responslbllitles/ Communicable diseases/ Matters of National Security
5) Worker's Compensation- We may disclose protected health information If necessary In compliance with laws relating to worker's compensation or other similar programs.
6) Health Oversight Activities- We may disclose your health Information to a health oversight agency that Is authorized to conduct audits, Investigations, Inspections, llcensure, etc.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
Right to Inspect and Copy: You have the right to inspect and copy your medical records. You must complete a written request and submit It to our privacy officer. There may be a fee for providing copies of medical records please enquire about these fees to front office staff. We may restrict your right to protected health Information/psychotherapy notes In certain circumstances as allowed by law.
Restrictions: You have the right to request a restriction of your protected health information. This means you may ask us not to disclose your Information for the purposes of treatment, payment, or healthcare operations. Please contact our privacy officer If you want to request any restrictions. We do not have to ag e to the restrictions that you request
Amendment: You have the right to request an amendment to your healthcare information If you feel It Is Incomplete or Inaccurate. You must submit your request in writing to our privacy officer, and Include an explanation of why the Information should be amended. Your request may be denied In certain circumstances.
Right to an Accounting of Disclosures: You have a right to receive a paper copy of this Notice, which you may request at any time. We reserve the right to change the terms of this notice, and will post any changes in our front office and on the practice website.
Questions and Complaints: You have a right to file a complaint with us If you feel we have not complied with our privacy policies. You may request a complaint form from the privacy officer and submit your complaint in writing. You may also complain to the Dept. of Health and Human Services. We will not retaliate against you If you flle a complaint.
How to contact us:
11755 Pointe Place, A-1 Roswell, GA 30076
404-450-0338
MICHAEL ROSEN, M.D.
11755 Pointe Place, A-1 Roswell, GA 30076
&
1120 Coggins Place
Marietta, GA 30060
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Your medical records are confidential and protected by state and federal laws Including the federal Health Insurance Portablllty and Accountability Act (HIPAA). Protected health Information is Information about your health record that may Identify you.
Uses and Disclosures of Protected Health Information:
Treatment: We may use or disclose your health information to provide, coordinate and or manage your health care services and treatment. We may disclose your health information to other healthcare professionals, such as therapists, doctors and/or nurses who also provide services to you to ensure proper coordination of care. All employees of Michael Rosen, M.D., are required to sign a workplace confldentlality agreement, and agree to access only the mlnlmally necessary healthcare Information In carrying out their primary Job function.
Payment: We may use or disclose your health Information to bill and collect payment for the services that we provide to you. This may involve office staff, health Insurance organizations, or other businesses that may become involved In helping to collect unpaid balances.
Health care Operations: We may use and disclose information about you for health care operations. These operations Include, but are not limited to, quality assessment, cost management, employee review, and business planning activities. We may use or dlsclose medical Information about you to remind you of an upcoming appointment, to check on you after you have received treatment, to obtain prior authorization for a treatment, etc. We may disclose your Information to contractors (business associates) who provide
certain services to us. Privacy and confidentiality Is very Important during the treatment of children and adQlescents. Many parents/caretakers want to know what transpired In psychotherapy sessions with children/ adolescents. However, some degree of confldentlallty Is essential In order to develop a
therapeutic alllance (particularly with adolescents). This alliance subsequently Improves the quality of their psychiatric care. Therefore, our providers will use their clinical Judgment In deciding whether and when to relay Information to parents that has been revealed to cllnlclans by patients. In most cases, If It Is felt that Information needs to be communicated to parents, patients will be encouraged to communicate this Information themselves. In cllnlcally urgent or emergent situations, we wlll llkely relay the·tnformatlon to parents directly.
1) Serious threat to health or safety- If we determine that you present a serious danger or threat to yourself or another, we may disclose Information to provide protection for you or the Intended victim.
2) Abuse/ Neglect- We will report to the appropriate authorities any circumstances of child abuse or neglect, elder abuse or neglect, or abuse or neglect directed towards a disabled person.
3) Legal proceedings. We may disclose protected health Information If required to do so by law I.e. court order, subpoena, etc. Our providers also reserve the right to use and disclose Information about you If doing so Is necessary to defend our providers from any legal action brought against our providers In relation to your care.
4) Public Health Responslbllitles/ Communicable diseases/ Matters of National Security
5) Worker's Compensation- We may disclose protected health information If necessary In compliance with laws relating to worker's compensation or other similar programs.
6) Health Oversight Activities- We may disclose your health Information to a health oversight agency that Is authorized to conduct audits, Investigations, Inspections, llcensure, etc.
YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
Right to Inspect and Copy: You have the right to inspect and copy your medical records. You must complete a written request and submit It to our privacy officer. There may be a fee for providing copies of medical records please enquire about these fees to front office staff. We may restrict your right to protected health Information/psychotherapy notes In certain circumstances as allowed by law.
Restrictions: You have the right to request a restriction of your protected health information. This means you may ask us not to disclose your Information for the purposes of treatment, payment, or healthcare operations. Please contact our privacy officer If you want to request any restrictions. We do not have to ag e to the restrictions that you request
Amendment: You have the right to request an amendment to your healthcare information If you feel It Is Incomplete or Inaccurate. You must submit your request in writing to our privacy officer, and Include an explanation of why the Information should be amended. Your request may be denied In certain circumstances.
Right to an Accounting of Disclosures: You have a right to receive a paper copy of this Notice, which you may request at any time. We reserve the right to change the terms of this notice, and will post any changes in our front office and on the practice website.
Questions and Complaints: You have a right to file a complaint with us If you feel we have not complied with our privacy policies. You may request a complaint form from the privacy officer and submit your complaint in writing. You may also complain to the Dept. of Health and Human Services. We will not retaliate against you If you flle a complaint.
How to contact us:
11755 Pointe Place, A-1 Roswell, GA 30076
404-450-0338