STOP AND READ BEFORE COMPLETING

Please keep in mind that completing this form does not guarantee an appointment.

Please note that we only accept clients 18-65 years old for Medication Management/Psychiatric Services.

We DO NOT fill out any paperwork including; FMLA, Short-Term/Long-Term disability and fit for duty. 

Please review the insurances that we are in network with on the New Patient tab of our websit. It is the patient’s responsibility to verify and confirm if their individual policy is in network with Modern Mind Clinic.You can call the number on the back of your insurance card and let them know you want to be seen for Psychiatric services. Give them our Tax ID # 85-3617430 to verify.

If you do not have any insurance and would like to pay out of pocket, we do offer CASH rates. You must pay for services prior to the appointment.

Your first psychiatric evaluation MUST be in person. You must be in the state of Michigan for all follow up telehealth visits. 

• I authorize use of this form on all my insurance submissions.
• I authorize release of Information to all my insurance companies.
• I understand that I am responsible for my bill (cash pay, deductible and/or copay included).
• I authorize billing for late fees and cancellation fees.
• I authorize billing for Tele-health/Tele-psychiatry visits.
• I authorize my health care provider to act as my agent in obtaining payment from my insurance company.
• I authorize direct payment to my health care provider.
• I permit a copy of this authorization to be used in place of the original.

Health Insurance Portability & Accountability Act (HIPAA) Privacy Acknowledgment Form

By signing I agree to have reviewed and agree to The Modern Mind Clinic HIPAA privacy Practice Notice embedded below. I understand that the privacy notice contains information that will help me get any questions I have answered regarding my privacy and provides me with the information to file a complaint related to the use of my protected health information.

IMPORTANT NOTICE TO ALL PATIENTS 

IT IS YOUR RESPONSIBILITY TO KNOW YOUR INDIVIDUAL INSURANCE POLICY. MANY INSURANCE POLICIES HAVE EXCLUSIONS. MOST HAVE DEDUCTIBLES, CO-PAYMENTS AND CO-INSURANCE.

SOME INSURANCE POLICIES MAY NOT COVER OUR SERVICES/ INCLUDING TELE-MEDICINE.

IT IS IMPORTANT FOR YOU TO CHECK WITH YOUR INSURANCE CARRIER TO DETERMINE IF THE PROVIDER YOU ARE SEEING IS LISTED AS AN "IN-NETWORK" PROVIDER. IF THEY ARE NOT LISTED AS AN "IN-NETWORK" PROVIDER YOU MAY HAVE A HIGHER DEDUCTIBLE AND/OR CO-PAY.

REGARDLESS OF INSURANCE COVERAGE, YOU ARE RESPONSIBLE FOR ALL BILLS NOT COVERED BY YOUR INSURANCE POLICY.

Although we are contracted with most insurance carriers, our services may not be covered by your particular insurance plan. Being referred to our clinic by another physician does not necessarily guarantee that your insurance will cover our services. Please remember that you are 100% responsible for all charges incurred: your physician's referral and verification of your insurance benefits are not a guarantee of payment.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider.

Additional services not covered by insurance companies include:

No-Show Policy: It is the patients responsibility to keep scheduled appointments or notify Modern Mind Clinic staff 48 hours prior to the scheduled appointment time. For new psychiatric evaluation patients or initial TMS mapping you will be billed a $150 fee and will be required to pay this fee in full prior to scheduling another appointment. As for follow-up patients you will be billed a $75 fee and will also be required to pay the fee in full prior to scheduling another appointment. Three no-show visits will result in discharge from our practice.

Late Cancellation Policy: You must give our office a 48-hour notice during normal business hours in an event that you need to cancel or reschedule your appointment. This will make the appointment time available to someone else. If appointments are canceled or rescheduled less than 48-hours prior to the appointment time a fee of $75 will be billed.

Active Balance Policy: We will not schedule patients who carry a balance larger than $200. Payments must be made in a timely manner.

I understand that Modern Mind Clinic reserves the right to any outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged an additional collections fee.

Fees are subject to change without notice.

Medical record copying will be charged according to State of Michigan rates.

By signing, I have read, understand and agree with the financial conditions described above. I authorize Modern Mind Clinic to run the credit card on file to pay for charges and/or outstanding balance. I also authorize Modern Mind Clinic to deduct Check Return Fees, Non-Covered Service Fees, and No-Show Fees.

Many of our patients allow their medical providers and/or family members to call and request medical or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to anyone you must sign this form.

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any authoized recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient. You have the right to revoke this consent in writing at any time.  

I authorize Modern Mind Clinic to release my medical and/or billing information to the following individual(s):

1. I hereby authorize the above named person or entity, its agents, employees and associates (the “Disclosing Party”), to release the protected health information described below to/from Modern Mind Clinic, its agents, employees and associates for up to 12 months.

2. The Protected health information to be disclosed is described as follows:

• My entire medical records including, but not limited to, any and all reports, and any notes (doctor’s nurses, and physical therapists) consultation reports and records, tests, test results, x-ray report, radiology reports, patient form pharmacy record, correspondence, notes, and memorandum, billing information, insurance information and invoice related to my care and treatment rendered at any time or date by or through Disclosed party’s office.

3. I understand that I may revoke this authorization in writing at any time by sending a written revocation to the Disclosing Party’s address set forth above, provided that this authorization cannot be revoked as to protected health information that has previously been released in reliance on this document.

4. I understand that a refusal to sign this authorization will not result in a denial of health care by the Disclosing Party or any other health care provider.

5. I understand that once the protected health information is disclosed, it may be re-disclosed individuals or organization that are not subject to the federal privacy regulations and would no longer be protected by those regulations.

6. I understand that I am entitled to a copy of this authorization.

7. I acknowledge the Disclosing Party and its agents, employees and associates are released from legal responsibility or liability for release of the above- described protected health information to the extent indicated and specifically authorization herein. 

Telepsychiatry involves the use of electronic communications and information technology to provide psychiatric and mental health services remotely. This allows patients and providers to communicate through secure video conferencing or other telecommunication technologies.

By signing this form, you acknowledge that you understand and agree to participate in telepsychiatry services.

Nature of Telepsychiatry Services
Telepsychiatry services may include, but are not limited to:

• Psychiatric evaluations
• Medication management
• Follow-up appointments
• Therapy or counseling services
• Patient education and treatment recommendations

Services will be provided through secure electronic communication platforms compliant with privacy regulations when possible.
Potential Benefits
Telepsychiatry may:

• Improve access to psychiatric care.
• Reduce travel time and associated costs.
• Allow continuity of care when in-person visits are not possible.

Potential Risks
Possible risks include:

• Technology failure or interruptions.
• Unauthorized access to electronic communications despite security safeguards.
• Limitations in the provider’s ability to perform certain physical examinations.

If technical difficulties occur, alternative arrangements such as phone contact or rescheduling may be necessary.
Confidentiality
All existing confidentiality protections under federal and state law apply to telepsychiatry services, including HIPAA regulations.

Information disclosed during sessions will remain confidential except in situations required by law, including:

• Risk of harm to self or others
• Suspected abuse or neglect
• Court orders or legal requirements

Patient Rights
You understand that:

• You may withdraw consent for telepsychiatry at any time without affecting your right to future treatment.
• You may request in-person services when available.
• You have the right to ask questions regarding telepsychiatry services at any time.

Emergency Situations
Telepsychiatry is not intended for emergency care.

If you are experiencing a mental health emergency, you should:

• Call 911 or go to the nearest emergency room.
• Contact the Suicide and Crisis Lifeline by dialing 911.

Patient agrees to provide the provider with their physical location and emergency contact information at the time of each session.
Technology Requirements
You agree to:

• Participate from a private and safe location.
• Use a secure internet connection when possible.
• Avoid recording sessions unless agreed upon by both parties.

Recording of telepsychiatry sessions by either party is prohibited without mutual consent.
Financial Responsibility
You understand that telepsychiatry services may be billed to your insurance or charged according to the practice’s fee schedule.

You are responsible for applicable copayments, deductibles, or uncovered services.

It is understood that:

 
1. No promises or guarantees shall be offered to the patient concerning treatment services.

2. This is only an Initial Evaluation with no agreement toward on-going care and management. The provider also reserves the right to cease on-going treatment of any patient who is non-compliant with his/her recommendations

3. Customary and standard treatment will be offered to the patient.

4. The treatment plan shall be developed with the patient’s understanding and approval.

5. Prescriptions refills can be requested during normal office hours and it may take up to 72 hours to fill the request.

6. Information shall be considered confidential but may be released to the client’s insurance company or auditing agencies to determine that client is receiving quality treatment.

7. Confidentiality may be breached, and information may be released if it is determined that the patient is a danger to self or others or is involved in child abuse. 

Authorization of Payments to Modern Mind Clinic from the client:

1. The patient is responsible for paying Modern Mind Clinic every time services are rendered, unless previous arrangements are made. As a courtesy, the office will submit any claims to your insurance carrier. I understand that I must assume responsibility for any charges not approved or paid for by my insurance company. 

Disclaimer: If you are a Self-Paying patient these rates may not apply to you.
Fees are subject to change without notice.

2. The patient is responsible for all missed appointments. There is a missed appointment charge of $75.00 for all follow-up appointments canceled less than 48 business hours prior to the appointment time.

3. Modern Mind Clinicians accept checks, Visa, American Express, Discover, Mastercard, FSA or HSA for payment.

4. The patient will be charged a $35.00 fee for any returned checks.

5. I have received a notice of the Privacy Practices (HIPAA).

6. Your Copay is due the day of your appointment. 

My signature below signifies that I accept responsibility for payment of services rendered.