Insurance Information:

Deductible Terms:

On the day of the appointment all deductible policies are required to pay the required amount.

Copay Terms:

All Copays are due at time of the appointment.

*We do not take any responsibilty for failed reimbursements by your insurance company.

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 MasterCard, Visa or American Express (NO PERSONAL CHECKS). You may also pay your bill by phone. Our fees are competitive compared to the usual in person appointments to charged by other psychiatrists and physicians in the area.

Insurance Claims/Billing

GanimMD, participates with some major insurance carriers. As a courtesy to our patients, we will file insurance claims for those insurances with which we participate. Please remember, any amount not covered by insurance is ultimately the patient's responsibility. A list of the major insurance companies we participate with is on this website, but please contact your insurance company to confirm that we are still participating. We require that you bring your insurance card and photo ID to all visits. Since at this time GanimMD is only providing online treatment/consultations, we are not able to accomodate patients with Medicaid, Managed or Third party medicaid programs or Medicare programs as well as clients with Disability or Temporary disability. Private pay is also not accepted by these clients as these clients will be better suited to receive treatment by a mental health clinic with more comprenehsive services.

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 3 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 credit card . 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 deal, steal, or conduct any illegal or disruptive activities in the doctor's office.

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 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, marijuana, cocaine, and other addictive substances.

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. We do not take any responsibility for any failure of Insurance Reimbursements. You will be billed for any balances you are responsible for. *Suboxone treatment is a service that is unable to be reimbursed from insurance and is private pay only.

17. You must let your provider or the staff know of any changes in your insurance policy, otherwise you will be responsible for the charges incurred.

18. 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.

Financial Policy Waiver/Policy:

We recommend your call your insurance company prior to rendering services from ganimmd.com to avoid such issues as not being reimbursed for your visits or to all ensure we are a covered and paneled provider under your insurance company.We are committed to providing you the best possible care.

At ganimmd.com we are priced competetively for clinical services. While a majority of our clients are private pay due to less hassle, and less restrictions from insurance companies as well more privacy with regards to sensitive medical information, we do try to accept certain insurances and if not we are able to provide you with a superbill which you can provide to your insurance company for reimbursement.

If you have medical insurance we are happy to try help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding.We will file your insurance claim with your primary insurance for you, however we ask that you pay any co- payment or deductible at the time services are rendered and the balance in full if your insurance has not paid in 60 days. For Insurance Co-payment we accept all major Credit Cards. We do not accept personal checks.We will do all we can to expedite insurance reimbursement, but you must realize that:

1. Your insurance is a contract between you, your employer and the insurance company. If we participate with your insurance plan, we are under contract to only charge what your company allows. Since each carriers "usual and customary" fees differ, we will take the appropriate discount when your insurance company pays our practice.

2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. These non-covered services are your responsibility. We must emphasize that as Medical Care Providers; while the filing of insurance claims is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered. We realize that temporary financial problems may affect payment of your account. If such problems arise, we encourage you to contact us promptly for assistance in the management of your account. If you have any questions about any of our financial policies, or any uncertainty regarding insurance coverage, please do not hesitate to ask. We are here to help you.

 

ASSIGNMENT OF INSURANCE BENEFITS & ACCEPTANCE OF FINANCIAL RESPONSIBILITY

I authorize the direct payment of any medical benefits to ganimmd.com for services rendered. I understand I am responsible for any and all usual and customary charges not paid as a result of this assignment. If the account is turned over to a third party, collection agency, or attorney, I understand a 10% service charge (minimum of $15) will be added to the balance, and I understand I will be responsible to pay all litigation expenses, court costs, and reasonable attorney's fees.

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 a 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 I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

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

8. 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.