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 $100.00 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.