INDIVIDUAL INTAKE FORM

I Understand*      that my engagement with Solar Health Services (herein referred to as "theClinic") or any of its providers, affiliates, or staff members are based on the following agreement.Therefore, I acknowledge an agree that any breach of these agreementsmay result in the termination of any and all of my relationships with the clinic or any of its providers,affiliates, and/or staff members.

I Understand*      that I (the patient) am fully responsible for the payment of all fees for services provided regardless of any insurance coverage I (we) may have. By initialing each section below, I attest that I have read, fully understand, and agreed to each of the policies contained herein. I understand and agree that in the clinics policy that the fee for any service provided is payable at the time of service. I understand that the clinic accepts cash and/or credit cards as a form of payment. 

    I Understand*      that if I have insurance, the clinic will, as a courtesy to me, file my claims on my behalf. I understand and agree that I am ultimately responsible for any fee(s) not covered by my insurance carrier. I understand that my insurance policy is a contract between my insurance company, and me and therefore will not hold the clinic responsible for their denial of coverage or for negotiating claims with insurance companies or other individuals. I agree that co-pays and non- covered services are payable at the time of services unless other arrangements have been made. If I am using an insurance plan, I hereby authorize payment of mental health benefits to the clinic and its providers. In the event that my insurance carrier declines my benefits, I acknowledge and agree that I am fully responsible for the declined charges and can expect them to be applied to my account and/or charged to the credit card I have placed on file with the clinic (See Credit card authorization form). I understand that the clinic will waft 45 days from the date of the dalm and If no payment has been received from the insurance provider, the remaining balance will become my responsibility. I further acknowledge that the clinic and its providers do not guarantee that payments will be authorized by my insurance company for services rendered; therefore, I acknowledge that I will not hold the clinic responsible for any adverse payment decisions or financial hardships that result from their denial of payments.

I Understand*     that if SOLAR HEALTH and its providers: do not take my insurance or have closed the new patient panel for my insurance, and I want to be seen here, then I will be a self pay patient and I as well as SOLAR HEALTH and its Providers will not file a claim with my insurance for the services rendered.

I Understand*      that the psychiatry providers do not provide any sort of documentation for FMLA shortterm disability forms etc any letters to employers schools etc and reports court documents requested by me You will be referred out for such documentation

I Understand*      and agree that it is my responsibility to schedule my medication management appointments as recommended by my psychiatrist in order to avoid lapses in medication. I understand that should I fail to schedule/attend a medication management appointment, that the clinic will charge $25 service fee for all refills called into my pharmacy if I run out of medication without having a scheduled appointment. I understand that refill requests need to be faxed to the clinic by my pharmacy at least 7 business days in advance and that non- emergency phone messages regarding medication will be returned within 48 hours. I understand medication refills are only addressed during business hours and request for refills cannot be initiated by a phone call. I further understand and agree that this fee is payable at the time the request is made and can be charged to my credit card on file (see Credit Card authorization form). 

I Understand* that, by signing this service agreement, I (patient) acknowledge that I am entering into a patient-doctor relationship with the provider at the clinic. I understand that, because of the nature of this relationship, it is not the general practice of the clinic or its providers to provide legal or forensic services. As such, I agree that in the event that any provider or staff member of the clinic is subpoenaed, summoned, noticed, or in any way requested or commanded to give testimony, produce records, appear or in any way be involved in any type of legal proceeding, that the patient- doctor relationship will be considered immediately terminated. At any time, the clinic wlll no longer provide services, but will fulfill court mandated legal obligations on a factual or forensic basis. 

I Understand*      and I agree that the clinic will charge $500 per hour for: actual time in court (including giving deposition), time spent waiting to testify, time spent preparing to testify including reviewing records, time spent traveling to and from the location of legal proceedings, and any time spent by staff of the clinic at the rate of $75 per hour for coordination schedules, compiling and assembling records, filing any notices, motions, etc. I further agree that I must retain the clinic of at least an 8-hour period for $3,500 (customary work-day) by arranging for the payment to be paid to the clinic before any subpoena is honored. I acknowledge I have been provided the opportunity to set up such arrangement with my credit card on the clinic (Credit Card authorization form). I understand that the clinic will refund any remaining balance of the retainer,after all court proceedings have concluded. 

I Agree* that if I, or any person that was present during any visit, subpoenas, summons, notices, or in any way requests or commands any provider or staff member of the clinic to give testimony, produce records, appear, or in any way be involved in any type of legal proceeding, that such subpoena, summons, notice, or other request will be deemed Invalid and void until, unless: (1) the retainer fees for the clinic's provider have been secured and (2) a HIPAA authorization to release information form has been filled out and signed by ALL parties that have been present during any visits. 

I Agree* that unless all these conditions have been satisfied, the dinic will engage an attorney to file appropriate legal responses, including, but not limited to, an Objection and Motion to Quash citing that this contractual agreement with the clinic has not been satisfied.

I Agree* that if the clinic or any of its providers or staff members incurs any financial expense for legal representation as a result of any legal proceeding as that I, or any person that was present during any visit, is involved with, that I will be fully responsible for the re-payment of such expenses. I further agree that in the clinic incurs any financial expenses for legal representation as a result of my actions; I authorize the clinic to immediately charge all such expenses for legal representation as a result of my actions; I authorize the clinic to Immediately charge all such expenses to my credit card on file (see Credit Card authorization form). Alternatively, those expenses can be deducted from the retainer I have placed with the clinic.

I Understand*      and agree that, it is not the general practice of the clinic or its providers to make any hospital or off-site visits. However, in the event that I or any family member of mine makes a request, a visit Is deemed absolutely necessary and, a provider Is willing, at his own discretion, to make a visit for my (our) benefit, the clinic will charge $500 per hour for actual time out of the office (including traveling to and from the hospital). 

I Understand* and agree that if I request to complete a psychological assessment provided by the clinic, or if my provider recommends that I complete such assessments that I am solely responsible for any and all costs associated with the administration and reporting of the results. I understand that it is the policy of the clinic that psychological testing/assessment are not billed to
any third party payers, including my insurance company. 

I Understand* and agree that if I am unable to attend my appointment at the clinic, I must cancel or re-schedule 2 business days prior to the scheduled appointment. Cancellations received after this time and No Shows will incur a $75 fee. I understand and agree that the clinic will charge my credit card on file for no-show or late cancellation. If payment is not secured through credit card, I understand that I will not be able to schedule another appointment with the clinic until I have paid the balance on my account. I further acknowledge and agree that my failure to pay these fees may result in the closing of my file and the termination of my relationship with the clinic. 

I Understand* and agree that accumulation of 3 or more noshows or late cancellations may result in the closing of my file and the termination of my relationship with the clinic.

I Understand*  that that the office staff or the clinic will make a good faith effort to complete reminder calls for my appointment before my scheduled appointment time. However, I understand that these reminder calls are a courtesy to me (the patient) and that on occasion circumstances may prohibit the completion of this task by office staff. I understand that managing my scheduled appointments is ultimately my responsibility, and that the missed appointment and late cancellation policy and related fee are applicable regardless of my receipt or lack thereof of a reminder call from the clinic staff. I understand that this policy is not meant to be punitive, but instead is to request consideration for the professionals who are providing me a valuable service. My appointment time is reserved for me at the exclusion of others who may be waiting to see a provider. Since the clinic is a fee-for service clinic, my late cancellation or failure to show for an appointment may result in a loss of revenue for the providers and/or the clinic in addition to keeping others from getting the help they may require. 

I Undestand* and agree the clinic charges $50 for the first 20 pages of medical records processing, preparation and printing. I understand each1page after the first 20 pages will incur a $0.50 charge per page. I understand and agree that if th clinic has to pay ANY fee to a third party (i.e. collection agency, attorney, court cost, etc.) for collection of payments, that based on this agreement, I will be responsible for those payments in addition to any service fees owned to the clinic.

I Understand*  that the clinic only accepts VISA/Master Card and does not accept personal checks. 

I Understand*  and agree that clinic reserves the right to review, revise, and otherwise modify this service agreement as necessity demands, without obtaining my express consent, and further acknowledge and agree that such changes in no way nullify my signature on this agreement, or release me from any of the financial or contractual obligation contained herein. 

I Understand*  and agree that as of the date of my first appointment at the clinic, I am entering into a doctor-patient relationship with my provider. I understand that the success of treatment is dependent upon a commitment to consistent attendance of regularly scheduled visits, until such time, mutually agreed upon between me and my provider; as such visits are deemed no longer necessary. I further acknowledge that my absence in the doctor-patient relationship, defined by a consistent lack of scheduled appointments or other communication with my provider and/or the support staff of the clinic for a period of 120 days, will result in the closing of my file, and the termination of this relationship. I understand that I am free to contact the clinic at any point after said termination, reinstate the doctor-patient relationship, and resume my treatment as a new patient at the clinic. 

I Understand*  and agree that if this agreement, agreements ancillary to this agreement, and related documents entered in connection with this agreement are signed when a party's signature is delivered by facsimile, email, or any other electronic medium. These signatures are and must be treated in all respects as having the same force and effect as original signatures.

I Understand*  and agree that if any one or more of the provisions contained in this agreement is for any reason held to be invalid illegal or unenforceable in any respect that invalidity illegality or unenforceability will not affect any other provisions of this agreement but this agreement will be construed as If those invalid illegal or unenforceable provisions had never been contained in it unless the deletion of those provisions C ould result in such material change so as to cause completion of the transactions contemplated by this agreement to be unreasonable.

I Understand*  that SOLAR HEALTH and its providers do not provide this service.

Month   /   Year*