Neha Khurana, MD Psychiatrist Georgia Behavioral Health, LLC

4720 Peachtree Ind. Blvd. Ste # 4101, Norcross, GA 30071 (678)861-6463

Welcome to our practice. The following information pertains to our practice policies. We look forward to working with you.

Your initial session is scheduled in person, in the office. The initial session is reserved for a thorough review of your history and current symptoms as well as medications. At the end of the session, we will discuss your diagnosis and treatment plan which may include talk therapy, medication management or a combination of both. We will provide you with a list of referrals for talk therapy. This office collaborates with your existing therapist for purposes of coordination of care. You may not be prescribed medications after your initial session if the provider does not deem them necessary. At the end of your first session, you may be referred out if our provider assesses that you will benefit from a higher or different level of care. This may include referral to Partial Hospital or Intensive Outpatient Programs or referral to a Community Service Board.

Follow-up appointments may be scheduled in office or virtually depending on the treatment plan. Follow-up appointments may be scheduled from 1 week to 4 months after your initial appointment based on the provider’s recommendation. The frequency of follow-up appointments may vary depending on the diagnosis, severity of illness, type of medication prescribed, response and side effects. Medication management appointments are 15-30 minutes in length depending on the type of medication and ongoing issues that are being addressed. Please note that our office does not offer same-day or crisis appointments. (Initial Below)

All paperwork is filled out in session with the patient and guardian present and at the discretion of our providers. This includes any school forms, FMLA, disability applications, or any other form of documentation required for work/ school/ legal purposes. A $50 fee applies to each application being filled out. Our office does not fill out disability

Your appointment time is reserved for you. Therefore, if you are not able to keep your appointment time, please call as soon as possible to cancel or reschedule your appointment. If you do not provide at least 24 hours' notice of

your canceled appointment or if you fail to show up for your appointment, you will be charged a no-show fee of

We will answer calls during business hours Monday-Friday. We will return phone calls within 24 hours with the exception of weekends and holidays. If you are experiencing an emergency and cannot wait to reach me, you should call 911 or go to the nearest emergency room. As soon as you are able to do so, please contact me to inform me of the situation. You can also reach the Georgia Crisis and Access Line at www.gcal.com. Medication changes are best addressed in session with our providers.

Before the commencement of each session, payment is required, encompassing co-pays or any outstanding balances resulting from deductibles that have not been met. We will initiate billing with your insurance company for the services rendered. We will receive an Explanation of Benefits (EOB) upon completing this process. The EOB will provide a detailed account of the claim processing and outline any additional financial obligations that may arise beyond the initial payment. It is important to note that certain insurance plans may entail varying out-of-pocket amounts specific to Mental Health Benefits. While our office will dutifully submit primary, secondary, and tertiary claims to our contracted payers on your behalf, it remains your responsibility, the patient, to cover the associated costs related to your appointments.

I understand that it is my financial responsibility for services provided until insurance deductible is met and

any co-pay thereafter or if my insurance becomes inactive, but I continue to seek services from GBH, LLC.

Full payment is due at the time service is rendered. I acknowledge responsibility for all fees incurred, including

those for documentation, no-shows, late cancellations, and prescription refills. Statement balances will be sent to patients monthly, with a 10% late fee assessed monthly. All balances 90 days past due will be deemed delinquent. We reserve the right to terminate patients from the practice with emergency care provided for 30 days. We send delinquent accounts to collections after 90 days.

For minor children of divorced parents-Payment is expected from the parent(s) bringing the child for treatment irrespective of the divorce decree. We will release pertinent medical records only to the patient’s Guardian or Custodial parent. The custodial parent or guardian who has signed the financial responsibility paperwork will be held accountable for the delinquent account.

Laboratory/Pathology: it is our standard practice to request blood work based on the specific nature of the illness and the

prescribed treatments. These services may involve an external reference laboratory under contract. Please be aware that any Lab/Path charges not covered by your medical insurance will be invoiced separately by an independent lab/path billing service. By seeking these diagnostic services, you acknowledge and accept responsibility for valid Lab/Path charges not covered by your medical insurance plan.

1. Medical Updates: Notify us promptly of significant changes in your psychiatric or medical condition or if your medication

regimen changes with an outside provider.

2. Pregnancy Notification: Inform us if you suspect or confirm pregnancy, as it will impact treatment recommendations.

3. Emergency Situations: If you're at risk of self-harm or harm to others, contact us immediately. For imminent risk, call 911 or

visit the nearest emergency room.

4. Communication Channels: I welcome emails for non-urgent, administrative communication. Please note that

the confidentiality of your email cannot be guaranteed. To discuss medical concerns, please call us at 678-861-6463 or email us at info@gbhpsych.com to schedule an appointment.

5. Medication Effects: Report drowsiness or significant side effects from medication, refrain from driving if affected, and it is

advised to avoid alcohol while on psychiatric medications.

6. Medication Changes: Consult us before altering your medication regimen. Medication Management is a collaborative

process. Changes without consultation may jeopardize health, disrupt collaboration, and lead to dismissal from our practice.

7. Animal Treatment: f you are seeking treatment with a service/therapy/emotional support animal, our practice does

NOT provide these services and are NOT trained in these areas to prescribe to our patients. Also, we do not write any

letters or documentations for your animals, so please refer to professionals that are trained in these areas to receive your documentation.

8. Appointment Scheduling and Refills:

a) It is your responsibility to Schedule a follow-up appointment at the end of your session.

b) Refill requests generate a $25 fee if outside routine appointments and are at the discretion of your provider.

c) Controlled substances require an appointment, and may not be called in without an appointment. Our office checks the GAPDMP prior to controlled substances to stay compliant with Georgia law

d) Our Office does NOT fill refill requests from the pharmacy. Please either call or text the office at (678) 861-6463 with your refill request.

e)  If the provider determines that a urine drug screening is necessary before prescribing any medication, the test will be

conducted in the office, and a $15.00 fee will be charged

9. Injection Services: Our office provides medication injections at a $15 cost per injection. If you would like one of our

providers to administer an injection for you, please contact our office to schedule an appointment for it. Payments must be made prior to injections given.

a) Three or more missed appointments in a 12-month period. b) Three or more cancellations with less than 24 hours' notice in a 12-month period. c) Abuse of prescribed medications. d) Positive urine drug screen for patients on controlled substances. e) Rude, aggressive, inappropriate, or hostile behavior towards staff, providers, or other patients.

Please briefly describe the problem or situation that has prompted you to call and seek treatment.

Fill out chart below on Substance Use History- Please specify amount and frequency

Please make sure to provide all the pertinent information listed or this may delay the sending of your prescriptions.

Please complete for any providers that you would like me to collaborate with including therapists, primary care physicians and other specialists

, here by authorize Dr. Neha Khurana to release

information from my medical records as described below to:

The request and authorization apply only to the following information:

Medical History/Physical Exam Discharge Summary Psychiatric Reports/Tests Psychiatric Evaluations Treatment Recommendations

Laboratory Reports Summary of Hospitalizations Psychological Reports Medications Course of Treatment

Consultations Progress Notes Teachers’ Reports Social History Developmental Hx

The release will expire in 12 months unless specified by you. I understand that I can cancel this authorization in writing at any time, except for action that has already been taken.

24 Hour Cancellation Policy- If you do not provide at least 24 hours' notice of your canceled appointment or if you fail to show up for your appointment, you will be charged $50 for a no-show appointment.

Telehealth/Virtual Appointment Policy: We will process all copays, deductibles, and co-insurance charges associated with your scheduled appointment the day before the designated appointment date. This transaction will be completed using the card information on file. It is imperative to note that failure to make the required payment or respond to any related inquiries will regrettably lead to the cancellation of the scheduled appointment. By signing this agreement, you authorize our office to charge the card below for the aforementioned charges above.

Please complete the information below:

I authorize Georgia Behavioral Health to charge my credit card indicated

below for payment of Psychiatric services for the following individual(s):

Credit card will be charged before each appointment for services rendered. Authorization can be cancelled at any time with written consent.

I authorize the above-named business to charge the credit card indicated in this authorization form according to the terms outlined above. I understand that this authorization will remain in effect until cancel it in writing, and I agree to notify the business in writing of any changes in my account information or termination of this authorization. This payment authorization is for the type of bill indicated above. I certify that I am an authorized user of this credit card and that I will not dispute the scheduled payments with my credit card company provided the transactions correspond to the terms indicated in this authorization form.

Account Type: Visa MasterCard Amex Discover

Patients require certain administrative services from our office that is not covered by your insurance company and that you will be responsible for. A list of administrative services with the associated fees is listed below.

1. Completion of all patient requested forms, letter, and/or documents requiring the provider's signature which also include administrative forms requested by third parties, (excludes your insurance company and/or another physician) will be provided to you at $50 per form.

Examples of the forms you the patient may request us to complete and provide:

a. School b. FMLA (Family Medical Leave Act) c. Disability d. Employer e. Patient Assistance Forms

2. All Prior Authorizations required or requested for medication can and will have a $25 fee applied before a prior authorization is submitted.

a. Appeals or Pro-longed Prior Authorization process are not required of the provider. Once a medication is decided upon by your provider, your insurance company may decide that you require a prior authorization prior to covering that medication. Becoming familiar with the prior authorization process my enable you to get your medication approved faster. But beware, not all medicines will be approved. Even if we and you do everything right, the insurance company may still refuse to cover your medicine. In the end, the insurance company is the one making the decision. To resolve this issue your provider my just change your prescription to another drug that does not require prior approvalSince your provider is not aware what your specific insurance company has on their formulary, this step will be done when possible and is an easy but sometimes timely solution. Other times a prior authorization will be completed which entails sending over paperwork requesting a specific medication to your insurance company. The waiting process begins and the practice will wait for further instructions from your insurance company, usually a request regarding medical records, as well as a reason why the prescribing provider would like to use that specific medication. Once all that is done a review and decision will occur, this process may take 2-3 weeks, in some circumstances, it can actually take months. Depending on the PA decision and our specific request or demand for the particular medication and/or appeals process may begin. The appeals process is a very lengthy and a time consuming process in which administrative services and physician services are not covered by your insurance, the time and effort require to fight an appeal process can be months.

3. Medical Record requests must be in writing/emailed with for following:

a. Full name of the patient b. Date of Birth c. Confirm how you would like to receive the requested medical record (if digital it will be password protected) d. Specific period or date of the medical Records you would like to obtain.