Review practice policy and Acknowledge:

Emergencies

I will try to respond to urgent issues within a reasonable time frame, but due to working in a hospital it sometimes becomes difficult. For true emergencies please call 911 or go to nearest hospital.

Refill Policy

We will try to honor all refill requests via email or telephone withi 48 hours, so please be aware that you will need to call 7 days prior to your "running out" of your medication to obtain this quick response. Otherwise, the expectation is to see your provider on next or same business day in the office by scheduling an appointment to obtain a refill.

Payment Policy

Payment will be requested at the time of service for all services that are non-covered or determined to be the patient's responsibility, including co-payments. Payment may be made by, Zelle, Venmo, Visa or American Express (NO PERSONAL CHECKS). Our fees are competitive compared to the appointments to charged by other psychiatrists and physicians in the metropolitan area.

Insurance Claims

In order to provide better care and avoid hurdles and limitations we no longer participate with insurances. We can provide you with the appropriate documentation for you to request out of network benefits if offered by your plan which most insurance plans offer.

Cancellation Policy

Please call at least 24 hours before your office visit to cancel an appointment. If you are rescheduling an appointment, please let me know so that I can cancel it and open the time for another patient. You may be assessed a missed appointment fee of $100.00, if you cancel on the same day as your appointment, or miss an appointment completely. Additionally, please keep in mind that consecutive cancellations will be considered as a noncompliance/no show equivalent and 2 or more no shows will be grounds for termination of Treatment. Once discharged or terminated from this practice you will not be accepted back.

Patient Consent/Contract for Treatment:

As a participant in treatment for medications and/or therapy, I freely and voluntarily agree to accept this treatment contract as follows:

1. I agree to keep and be on time to all my scheduled appointments.

2. I agree to adhere to the payment policy outlined by this office. Payments must be made via cash, credit card or zelle, venmo . Personal checks are NOT acceptable.

3. I agree to conduct myself in a courteous manner during the appointment.

4. I agree not to sell, share, or give any of my medication to another person. I understand that such mishandling of my medication is a serious violation of this agreement and would result in my treatment being terminated without any recourse for appeal.

5. I agree not to record, steal, or conduct any illegal or disruptive activities in the doctor's office or during the telemedicine visits.

6. I understand that if dealing or stealing or if any illegal or disruptive activities are observed or suspected by employees of the pharmacy where my medications are filled, that the behavior will be reported to my doctor's office and could result in my treatment being terminated without any recourse for appeal.

7. I agree that my medication/prescription can only be given to me at my regular office visits. A missed visit may result in my not being able to get my medication/prescription until the next scheduled visit.

8. I agree that the medication I receive is my responsibility and I agree to keep it in a safe, secure place. I agree that lost medication will not be replaced regardless of why it was lost.

9. I agree not to obtain medications from any doctors, dentists, pharmacies, or other sources without telling my treating physician.

10. I will let my physician know of all medications that I am being currently prescribed including those given by other treatment providers.

11. I agree to take my medication as my doctor has instructed and not to alter the way I take my medication without first consulting my doctor.

12. I understand that medication alone is not sufficient treatment for my condition, and when applicable I agree to participate in counseling as discussed and agreed upon with my doctor and specified in my treatment plan.

13. I agree to abstain from alcohol, opioid, cocaine, and other addictive substances that are harmful to my treatment.

14. I agree to provide random urine samples or testing (if requested) and have my doctor test my blood alcohol level if necessary.

15. If there is a problem and the patient cannot make the scheduled appointment please call the office and leave a message. Failure to contact the clinic and not showing up at the scheduled appointment may result in a $50.00 fee that will be assessed at the Following visit.

16. Suboxone treatment is a service is private pay only.

17. If you have not been compliant with your treatment visits for a period of 90 days, your case will be considered closed/inactive and be terminated from treatment of which we will send you a notification on the 90th day.

19. If you are terminated from the practice you will not be able to reschedule with our practice. You will be referred to other providers whom provide similar services.

20. I understand that violations of the above may be grounds for termination of treatment.

I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of Contract for Treatment by ganim.com.

I agree the above is reviewed and also accurately reported information and by signing my name, I affirm my acknowledgement of Financial Waiver/Policy.

Telemedicine Consent Form

Provider: Nader Ganim, MD.

You MUST be an Arizona, Florida or New York resident to participate in telemedicine services provided by Ganimmd offices and Proof of residence must be provided prior to conducting sessions.

I hereby consent to engaging in telemedicine with ganimmd.com, as part of my psychiatry evaluations and medication management sessions. I understand that "telemedicine" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telemedicine also involves the communication of my medical/mental information, both orally and visually, to health care practitioners located in NY, AZ, and Fl as well as outside these states.

I understand that I have the following rights with respect to telemedicine:

(1) I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled.

(2) The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.

I also understand that the dissemination of any personally identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without my written consent.

(3) I understand that there are risks and consequences from telemedicine, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.

In addition, I understand that telemedicine based services and care may not be as complete as face-to-face services. I also understand that if my psychiatrist believes I would be better served by another form of psychiatric services (e.g. face-to-face services) I will be referred to a psychiatrist who can provide such services in my area. I understand that there are potential risks and benefits associated with any form of psychiatry, and that despite my efforts and the efforts of my psychiatrist, my condition may not be improve, and in some cases may even get worse.

(4) I understand that I may benefit from telemedicine, but that results cannot be guaranteed or assured.

(5) I understand that I have a right to access my medical information and copies of medical records in accordance with state laws.

(6) I understand that even if I am accessing the provider from my own home, my provider may contact police or 911 in the event of life threatening emergencies. 

(7) I will not record any phone or video session without my Dr. Ganim's written permission and I understand that Dr. Ganim will not record any session without my written permission

(8) I agree not to obtain controlled substances from other physicians without notifying Dr. Ganim I understand that Dr. Ganim may review my prescription history by accessing an online Prescription Drug Monitoring Program at any time.

(9) I understand that all appointments will be paid in advance using the online scheduling system on Dr Ganim's website. I understand that arrival for my appointment 10 minutes late (or more) is considered a missed visit;
payments for missed visits will not be refunded under any circumstances.

(10) Payment for and completion of a telemedicine session is not a guarantee of a prescription; prescriptions are offered only under the appropriate clinical conditions determined by Dr. Ganim. Prescriptions will not be ordered or refilled
following a missed appointment.  

 

I have read and understand the information provided above. I have discussed it with my Psychiatrist and all of my questions have been answered to my satisfaction and I hereby consent to participate in telemedicine.

 

4. This medical information may be used by the person I authorize to receive this information for medical treatment or consultation, billing or claims payment, or other purposes as I may direct.

5. This authorization shall be in force and effect until ___Terminated from treatment or Discharged___, at which time this authorization expires.

6. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization.

7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.