Information For Patients
Alis Family Psychiatry
Oregon Office: 535 Washington St Hillsboro, OR 97123
Phone: 503.922.1999
Virginia Beach Office: 6350 Center Drive, Suite 102 Norfolk VA 23502
Phone: 757.239.2293
In private practice, I do not have on-call coverage for emergent situations or have assisting prescribers to support emergent needs. Additionally, outpatient care is not equipped for behavioral health emergencies and local hospital ER/ED help should be sought. For after hours, weekends, and if you need help immediately you should call the crisis clinic 1.866.4 CRISIS (1.866.427.4747).
Who we Serve:
We care for children, adolescents, adults ages 4 - 65, and their families in an in-person and tele psychiatry outpatient clinic. If there is any reason why we are not the best place to care for you, we will explain why and direct you where to find care elsewhere.
If you have any issues with our services or would like to share feedback, you can submit it via our Formal Complaint Form or by sending us feedback at https://www.alispsych.com/contactus
Inclusion of Virtual Assistants:
We want to keep you informed about the enhancements we've made to our healthcare services to ensure a seamless and efficient experience for you. As part of these efforts, we want to let you know that during your appointments, your healthcare provider, Tina, may work alongside virtual assistants to optimize the quality of care you receive.
The virtual assistants who may be present during your appointments will be disclosed during appointments.
These virtual assistants play a supportive role during the appointment, working under the supervision of Tina to facilitate administrative and clinical tasks. Their presence is aimed at improving the overall efficiency and effectiveness of your healthcare experience.
Additionally, please note that the virtual assistants may communicate with you via text or HIPAA-secured email as part of the appointment process. This communication may include appointment reminders, follow-up instructions, or other relevant information. Rest assured that any communication will adhere to strict confidentiality and privacy standards to safeguard your personal health information.
Tina remains ultimately responsible for your care, and the virtual assistants are an integral part of our commitment to providing exceptional service.
If you have any questions or concerns regarding the involvement of virtual assistants or their communication methods, feel free to discuss them with Tina.
CONSENT FOR TREATMENT
I understand that this voluntary consent is for an initial psychiatric assessment and treatment, and/or substance abuse assessment, and treatment in which I am agreeing to voluntarily participate in at Alis Family Psychiatry. I understand that this consent is voluntary and that I can withdraw my consent for treatment at any time.
The purpose of this voluntary assessment is to evaluate my current mental health, and/or substance abuse needs, and to develop specific assessment recommendations related to my concerns which have brought me to Alis Family Psychiatry.
I understand the initial assessment will be conducted by an Alis Family Psychiatry with a Psychiatric Mental Health Nurse Practitioner, PMHNP, who is additionally versed in Addiction. The assessment will consist of interviews between the provider and myself. Neuro-Cognitive testing will likely be ordered in addition to objective psychiatric scale testing for objective measurement of baseline and ongoing treatment to evaluate my ongoing needs / and progression, for more thorough, and consistent care at Alis Family Psychiatry by the PMHNP. In addition, urine and/or oral drug screenings will be required for patients who are currently prescribed or will be prescribed stimulant or benzodiazepine medications. These screenings, along with blood serum lab work and an ECG/EKG, are part of Alis Family Psychiatry’s commitment to providing evidence-based care in accordance with current clinical standards. Some mental health disorders have medical and/or biological origins and may require a consultation with a family nurse practitioner and/or physician.
Medication decision-making consists of collateral information obtained via reported history, objective findings, as outlined in the previous paragraph, and decision-making by the provider and will likely NOT be initiated at the first visit. The initial visit will be conducted by our in-house Family Nurse Practitioner (FNP), who will perform a comprehensive medical history and health assessment as part of your intake process.
Patients have the right to have their opinions known, considered, and documented by the treatment team, but patient opinion will not dictate medication prescribing.
I understand the practitioner may need to discuss my case, confidentially, with a professional treatment team to provide quality service. I am aware additional professional staff may be asked to participate in the evaluation and treatment, not limited to a pharmacist, LCSW, PLC, nurse, scribe, etc. I understand these discussions will be kept confidential unless I authorize that information be released or unless allowed or required by law. These exceptions to confidentiality are referenced in the Notice of Information Practices handout, which I acknowledge and have been given a copy of for my review.
Purpose of State and Federal Laws regarding Disclosure:
The purpose of state and federal laws regarding disclosure is to provide protection for public health and safety and to ensure the maintenance of client confidentiality. The Virginia/Oregon State Department of Health Licenses Mental Health Professionals and provides a complaint process against those providers who would commit acts of unprofessional conduct. Clients have the right to choose the healthcare professional who best serves their needs. Clients/families have the right to refuse treatment.
Practice:
Alis Family Psychiatry works as an independent contracted provider. All services rendered are representative of the Alis Family Psychiatry provider(s) health care license, independent business, and practice style. Alis Family Psychiatry has a dual board-certified PMHNP(s), Psychiatric Mental Health Care Nurse Practitioner(s), FNPs Family Nurse Practitioner(s) in the State of Virginia/Oregon.
I understand that some treatment recommendations may be addressed during the initial interview(s). Once the assessment is complete and an initial treatment plan has been formulated that I agree to with shared decision-making, I will be allowed to review and discuss with the practitioner the results of the assessment, the nature of the condition, and any/all treatment recommendations, including alternatives to these recommendations.
Alis Family Psychiatry is an outpatient and telepsychiatry behavioral health clinic. Alis Psychiatry is not equipped to handle crises regarding a patient’s behavioral health without an appointment. It is Alis Family Psychiatry’s policy that the patient goes to the local hospital ER/ED and/or call the suicide hotline when Alis Family Psychiatry is not available to provide outpatient behavioral health services and/or if the patient’s provider is unavailable to assist with a crisis. Alis Family Psychiatry cannot assist with patients’ medications if they are new to Alis Family Psychiatry and have not been fully evaluated. Patients must first have an appointment before ANY medications can be prescribed and medications are not routinely prescribed at the first visit. Controlled substances will not be issued before the collection of initial laboratory testing.
A patient may be involuntarily discharged from treatment at Alis Family Psychiatry because of the patient’s inability to pay for services or for behavior that is a reasonable result of mental health symptoms only as provided in par. A warning letter of discharge will be mailed to you, when appropriate, regarding any reason you may be discharged, as a patient can also receive a discharge letter without the warning when appropriate.
GOOD FAITH ESTIMATE*
Under Section 2799B-6 of the Public Health Service Act, healthcare providers are required to provide individuals who do not have health insurance or opt out of using their health insurance, upon request or at the time of scheduling healthcare items and services, a “Good Faith Estimate” of expected charges.
Note: A Good Faith Estimate is intended for you to be aware of estimated fees. The estimate does NOT mean you need to commit to the length or frequency of therapy sessions.
You have the right to receive a Good Faith Estimate for the total expected cost of any non-emergency items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
Make sure your healthcare provider gives you a Good Faith Estimate in writing at least 1 business day before your medical service or item. You can also ask your healthcare provider, and any other provider you choose, for a Good Faith Estimate before you schedule an item or service.
The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur.
If you are billed at least $400 more than the sum provided in your Good Faith Estimate, you can dispute the bill.
Make sure to save a copy or picture of your Good Faith Estimate.
For questions or more information about your right to a Good Faith Estimate, visit www.cms.gov/nosurprises.
*Disclaimer: This legislation is still being interpreted. The above statement is an effort to provide those seeking mental health services what is currently believed to be important and required to share with both prospective and current clients. If new information involving this Act develops, this page will be updated to reflect those developments.
Tele Psychiatry:
I (name of patient) hereby consent to engaging in telepsychiatry with Alis Family Psychiatry and participating providers for the management of medication and psychotherapy. I understand that “telepsychiatry” includes the practice of health care delivery, diagnosis, consolation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I understand that telepsychiatry also involves the communication of my medical/mental health information, both orally and visually, to healthcare practitioners located in Virginia and Oregon, or outside of these states temporarily.
I understand that I have the following rights concerning telemedicine:
(1) I accept that I need access to a PC, laptop, or mobile device and a good internet connection to have an efficient telepsychiatry appointment.
(2) 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.
(3) I also understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.
(4) I understand that there are risks and consequences from telemedicine, including but not limited to, the possibility, despite reasonable effects on the part of my qualified Psychiatric Mental Health Nurse Practitioner, that: the transmission of my medication information could be disrupted or distorted by technical failures, the transmission of my medication 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 telepsychiatry-based services and care may not be as complete as face-to-face services, I also understand that if my qualified Psychiatric Mental Health Nurse Practitioner believes I would be better served by another form of mental health services (e.g., face-to-face services) I will be deferred elsewhere. Finally, 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 qualified Psychiatric Mental Health Nurse Practitioner, my condition may not improve and in some cases may even get worse.
(5) I understand that I may benefit from telepsychiatry, but that results cannot be guaranteed or assured.
(6) I understand that all existing laws regarding access to medical information and copies of medical records apply to telepsychiatry appointments.
(7) Telecommunications with patients will not be recorded and stored. Patients’ medical information obtained by the diagnosis and analysis can be used anonymously for further improvements in scientific studies.
Alis Family Psychiatry Consent to Treatment - Confidentiality
Limits of confidentiality
Contents of all sessions are considered to be confidential. Both verbal information and written records about a client cannot be shared with another party without the written consent of the client or the client’s legal guardian. Note exceptions are as follows:
Duty to warn and Protect
When a client discloses the intention of a plan to harm another person, the mental health professional is required to warn the intended victim and report this information to legal authorities. In cases in which the client discloses or implies a suicide plan, the healthcare professional is required to notify legal authorities and make reasonable attempts to notify legal authorities and make reasonable attempts to notify legal authorities and make reasonable attempts to notify the family of the client.
Abuse of Children and Vulnerable Adults
If a client states or suggests that he or she is abusing a child (or vulnerable adult) or has recently abused a child (or vulnerable adult), or a child (or vulnerable adult) is in danger of abuse, the mental health professional is required to report this information to the appropriate social service and/or legal authorities.
Parental Exposure to Controlled Substances
Mental health care professionals are required to report admitted parental exposure to controlled substances that are potentially harmful.
Minors/Guardianship
Parents or legal guardians of non-emancipated minor clients have the right to request the client’s records unless it is determined that access would have a detrimental effect on the medical relationship, or the client’s physical safety or psychological well-being.
Judicial or Administrative Proceedings
Healthcare professionals are required to release records of clients when a court order has been placed. In the event of a court order, only the minimally acceptable amount of information will be revealed. Additionally, if a client files a complaint or a lawsuit against anyone affiliated with or working with the Alis Family Health team; relevant client files a complaint or a lawsuit against anyone affiliated with or working with Alis Family Health Team; relevant information regarding the client may be disclosed to formulate an appropriate defense.
Insurance Providers (when applicable)
Insurance companies and other third-party payers are given information that they request regarding services to clients. Information that may be requested includes, but is not limited to: Types of services, dates/times of services, diagnosis, treatment plan and description or impairment, progress of patient, case notes, and summaries.
Overview of Privacy Policies
Alis Family Psychiatry policy and federal regulations protect the privacy of our patients; health information The Health Insurance Portability and Accountability Act (HIPAA) is a set of federal rules that defines certain rights regarding their information. Alay Psychiatry has policies that reflect these regulations as well as the best ethical standards. These rules protect information that is collected or maintained, (verbally, in paper, or electronic format) that can be linked back to an individual patient and is related to his or her health, the provision of health care services, or the payment for health care services. This includes, but is not limited to, clinical information, billing, financial information, and demographic/scheduling information. Even the fact that an individual has received care at Alis Family Health Team is protected by Alis Family Health Team policy and federal regulations.
Alis Family Psychiatry employs scribes. Your Alis Family Psychiatry provider will most likely be at the appointment with the scribe and you, as the patient. Your provider will be orchestrating the management of the medications at those appointments when they occur, as a licensed PMHNP-BC will always need to prescribe the patients’ medications, however, the scribe may be verifying/implementing scale testing, vitals, etc. If you, the patient, have questions/concerns or if you do not give consent to our policies, please notify the office staff of this, and do not sign, as by signing below you agree you have acknowledged Alis Family Psychiatry policies and give consent to have appointments with scribes and your prescriber.
Medication Refill Policy
Alis Family Psychiatry Prescribing Provider participates with electronic prescribing directly to your mail order and local pharmacies. Our goal is to assist our patients with prescription requests in an efficient and timely manner. Due to the volume of prescription requests, we have created the following guidelines to help meet these goals.
1. It is the patient’s responsibility to notify the office promptly when refills are necessary. Approval of your refill may take up to three (5) business days, so do not wait to call. If you use a mail-order pharmacy, please contact us fourteen (14) days before your medication is due to run out.
2. Medication reflls will only be addressed during regular office hours (Monday – Thursday 7:00am – 3:00pm EST) Please notify your provider on the next business day if you find yourself out of medication after hours. No prescriptions will be refilled on Fridays, Saturdays, Sundays, or Holidays.
3. Prescription refills require close monitoring by your provider to ensure their safety and effectiveness. Your provider will prescribe the appropriate number of prescription refills to last until your next scheduled appointment. Generally, when you are down to zero refills, not out of medication, refills are labeled on your medication bottle, and it is time to schedule a follow-up appointment. We prefer you request any refills of your medications at the beginning of your office visit. Call your pharmacy for any CONTROLLED medications, no refills are given per pharmacy state law, but you may have a prescription at the pharmacy for you to pick up, thus, FIRST contact your selected pharmacy.
If we need to transfer a prescription to a new location, a $15.00 fee will apply. We will only process one transfer per prescription. Otherwise, there is a risk of being audited for over-issuing controlled substances. The only exception is Tricare prescriptions sent to DOD bases.
4. Patients requesting new prescriptions or on controlled prescriptions must be seen for an appointment. CONTROLLED substances are not prescribed without an appointment with a provider and the expectation is that medications are NOT filled and/or prescribed at the first appointment(s).
5. Refills can only be authorized on medication prescribed by providers from our office. We will not refill medications prescribed by other providers.
6. Some medications require prior authorization. Depending on your insurance, this process may involve several steps by both your pharmacy and your provider. The providers and pharmacies are familiar with this process and will handle the prior authorization as quickly as possible. Only your pharmacy is notified of the approval status. Neither the pharmacy nor the provider can guarantee that your insurance company will approve the medication. Please check with your pharmacy or your insurance company for updates.
7. It is important to keep your scheduled appointment to ensure that you receive timely refills. Repeated no-shows or cancellations will result in a denial of refills as well as a possible discharge.
8. If you have any questions regarding medications, please discuss these during your appointment. If for any reason, you feel your medication needs to be adjusted or changed, please contact us immediately to make an appointment with your provider as medication adjustments require an appointment. Unilateral (patient directed) dose changes are not permitted and are grounds for discharge. Alis Family Psychiatry will not refill a prescription that is required as a result of a unilateral (patient directed) medication increase.
Attendance and Cancellations Policy:
It is important to come to all of your scheduled visits. Not attending appointments delays your care and your prescriptions. If you are not able to make an appointment, call (757) 239-2293/(503) 922-1999 as soon as possible.
A ‘No Call / No Show is when you:
Do not show up for a scheduled appointment.
A ‘Late Cancel’ is when you
Cancel a visit less than 48 hours before your appointment (including after the scheduled appointment time)
Arrive after the 8th minute of your appointment time has passed.
If you have 3 no calls / no shows, and/or late cancellations within a 1-year time from your first visit with your provider, you may be discharged from the clinic.
We value your time and are committed to providing quality care. To ensure the efficiency of our services and availability to all patients, we have implemented a no-show policy. Please take note of the following guidelines:
A flat fee of $150 will be charged for each missed evaluation appointment without prior cancellation of 48 hours.
1st no show: No charge will be applied. This serves as a courtesy reminder of our attendance policy.
2nd No-Show: A charge of $70 will be applied to your account. Fee will require collection prior to rescheduling additional appointments.
3rd no show: In the event of a third no-show, a charge of $70 will be applied to your account. Continued missed appointments may result in dismissal from the practice. All outstanding fees must be paid before any consideration of future scheduling.
Addendum: Policy does not apply for medicaid/medicare. However, termination warning will be sent accordingly.
Conditions for Charges:
· The patient is responsible for notifying us of any cancellation at least 48 hours in advance to avoid charges. The patient has the option to cancel an appointment via the patient portal.
Rationale:
· This policy is in place to ensure fair and equitable access to our services for all patients.
· The charges help cover the costs associated with missed appointments and allow us to maintain a high standard of care for everyone.
Fees associated with ‘No Call / No Show’ and ‘Late Cancel’ are NOT covered by insurance.
New Patients
There will be 1-2 initial visits to ensure proper assessment and thorough evaluation. Medications may not be prescribed on the first visit. The first appointment is approximately 60, or sixty minutes, and subsequent appointments will range from 20-40 minutes depending on each person’s individual needs and preferences. These appointments will be used to evaluate, educate, and determine a mental health diagnosis, as well as discuss the side effects and efficacy of any/all prescribed medication. Weekly to two-week visits covering neurocognitive testing and psychological scale testing, ECG/EKG, serum blood work, and urine/blood serum/oral drug screen, will then be ordered with results obtained to fully develop a current, evidenced based treatment plan with notating objective changes of symptoms to being stabilized and potentially alleviated. Shared decision-making will focus on determining the best, personalized frequency of appointments going forward based on your health, treatment goals, and stability of your condition. Controlled medications will require 4-8 weeks, or fewer visits, to be reflective of Oregon/Virginia pharmacy refill regulations. A contract will be signed by both Tina and the patient prior to the issue of any controlled substances so that all expectations are clear before initiation of treatment. Any serum laboratory requests or screenings that are ordered are expected to be done prior to the next appointment (refill) or Tina may not refill medications until testing is resulted. For stable, non-medication adjustment clients, neuro-cognitive testing will be done/requested per Tina’s treatment plan up to three times per year, or yearly.
Financial Agreement
All services rendered are representative of the health care license and practice style of the providers at the independent business of Alis Family Psychiatry as a board-certified PMHNP in the State of Virginia.
I hereby give my permission for Alis Family Psychiatry to extend to me, as the patient, behavioral health care treatment. I allow the administrative services for billing at Alis Family Psychiatry to file for insurance benefits to pay for the care I receive. I understand that Alis Family Psychiatry will have to send my behavioral health care record information to my insurance company and that I must pay my share of the costs. I agree that I must pay the cost of these services if my insurance does not pay or I do not have insurance to cover. I understand that I have the right to refuse any procedure or treatment and I have the right to discuss all my medical treatments with my provider. Although health insurance may aid in payment, I understand that I am ultimately responsible for paying for services and appointments with Alis Family Psychiatry.
If I have a co-payment or if I am self-paying (no insurance or insurance not accepted by Alis Family Psychiatry), I will be expected to pay that amount at the time the services are provided, as otherwise, I will not be seen. If I am self-pay and I have not paid 48 hours before the appointment, I understand that I will not be seen and that medications, if prescribed, will not be filled. If a copay is not made, a bill will be sent to me, the client for all copays not paid. If I have a balance on my account, that will need to be paid in FULL before I can be seen and before any medications will be refilled.
Alis Family Psychiatry will work with me in getting payments processed, as well as the Alis Family Psychiatry billing department. If I do not receive a bill and I have a balance, I will initiate contact with Alis Family Psychiatry so that they can assist.
Telephone consultations, reports, and letters to other professionals may be provided as a courtesy at no fee if they are rare and require less than 5 minutes. Most services requiring more time, such as lengthy phone consultations, reports, letters, or conferences, will have an hourly fee corresponding with your hourly appointment rate and are not services billable to insurance.
I understand that it is my responsibility to find out if Alis Family Psychiatry is a participating provider with my insurance plan. If my insurance company requires me to obtain authorization from them before treatment, and I do not do so, I am responsible for payment in full at the time services are provided.
If I fail to cancel a scheduled appointment with less than a 48-hour notice, we cannot use this time for another client, and I agree to be billed $395.00 for an initial visit, $295.00 for a 40–60-minute appointment, and $195.00 for a 20–39-minute appointment. These fees will not be billed to my insurance company but rather, directly to me, and I will be fiscally responsible. I fully understand that 3 or more missed appointments reduce therapeutic alliance and that I may be discharged from Alis Family Psychiatry as a client. Exceptions will be made ONLY on a case-by-case basis and at the discretion of Alis Family Psychiatry.
If my account balance exceeds $150 due to unpaid charges for previous services rendered, it is Alis Family Psychiatry’s policy to require full settlement of the outstanding balance before further appointments can be scheduled and full settlement of the outstanding balance before medication prescriptions are provided.
This policy is in place to ensure Alis Family Psychiatry can continue offering the best possible care and maintain a smooth workflow for all its patients. Alis Family Psychiatry asked to be mindful of this policy and take appropriate steps to address any future financial obligations promptly.
Alis Family Psychiatry reserves the right to collect any unpaid balances. As a client, I fully understand and acknowledge that if I am not making agreed-upon regular monthly payments on the account balance, or no action to pay the bill has been taken, a collection agency by Alis Family Psychiatry may take legal action to secure payment, as authorized by state or federal law, and the collections actions will become part of my credit record. Clients will be notified in writing before an account is referred for collection. Any outstanding balances will likely result in a discharge.
Please note: Most clinical issues should be shared in our session. If calls and case management become excessive, I may need to charge for case management time. I will always inform you before providing this service and before billing for it.
Financial Policies & Responsibility
Fees for Services: Alis Family Psychiatry providers operate independently and accept a range of insurance plans. Payment in full is due at the time of each session, including private pay, copays, coinsurance, and deductibles.
Balance Over $150: I understand that for balances exceeding $150, I might not be able to secure future appointments or receive any other services, such as medication refills, until my balance is paid. Additionally, any scheduled appointments might be canceled if my balance remains unpaid 3 days prior to the scheduled appointment date.
Insurance: If you use insurance benefits, ensure that your provider is in-network. If your visit is out-of-network, you agree to pay the 'out-of-network' rates or private pay fees.
Scenario
Estimated Out-of-Pocket Cost
Self‑pay/cash — new patient visit
$150–$330 (depending on provider)
Self‑pay/cash — follow‑up visit
$80–$180 (typical range)
In‑network insurance — copay/coinsurance
$0–$75 (based on plan terms)
Insurance Eligibility Verification: Provide accurate insurance information and a copy of your insurance card before your initial visit. Let us know if your insurance changes to avoid coverage issues.
Credit Cards on File: You are required to keep a credit card on file to cover any balances. Cards are stored securely, and you will receive an email notification for each transaction.
Please do understand that:
• A valid credit or debit card must be provided and kept on file as a condition for scheduling appointments, receiving medication refills, or participating in any consults through Visionary Psychiatry.
• This card may be used to pay for copays, deductibles, outstanding balances, or any charges not covered by my insurance provider.
• Whenever my credit card is charged, I will receive an email notification with details of the transaction.
• I have the right to update or change my payment method at any time by notifying the billing department.
• All credit card information will be securely stored and handled in compliance with HIPAA and PCI-DSS standards.
• I hereby authorize Alis Family Psychiatry, legally recognized DBA entity of McArthur, Gruff & Associates, LLC to charge my credit card for services rendered. This authorization applies to all charges, including but not limited to copays, deductibles, coinsurance, and any remaining patient balances provided to me or the patient under my care.
Collections Efforts: If your card is declined, you will be contacted for updated payment instructions. Unpaid balances without a payment plan after 120 days will be turned over to a collection agency, which may impact your credit.
Our Responsibilities
We are required by law to maintain the privacy and security of protected health information. We must follow the practices described in this notice and give you a copy of it. We will inform you promptly if a breach occurs that may have compromised the privacy or security of information. We will not market or sell your personal information without your written permission, except as described in this Notice of Privacy Practices.
Changes to the Terms of this Notice
We reserve the right to change the terms of this notice at any time. Any new notice will be effective for all PHI we maintain at that time. We will make the revised notice available on the Alis Family Psychiatry website.
Contact Information
If you have questions about this notice or need additional information, you can contact our Privacy Officer. If you believe your rights have been violated, you can fle a complaint with our Privacy Officer or the Department of Health and Human Services. All complaints must be in writing and describe the concern
Acknowledgment
By signing this disclosure statement, you acknowledge and agree to the following terms:
You authorize Alis Family Psychiatry to release information to insurance carriers and to be paid directly for services billed.
You accept responsibility for charges not covered by insurance, including copays, coinsurance, deductibles, refusal to pay due to lack of authorization, and late cancellation fees.
You authorize Alis Family Psychiatry to charge your credit card on file for charges deemed as 'patient responsibility' by your insurance company.
I authorize Alis Family Psychiatry to create my patient profile in their Practice Fusion system for the purposes of verifying insurance benefits, coordinating treatment, and facilitating future scheduling communication. I consent to the use of my demographic and relevant health information as needed and understand that all data will be handled in compliance with HIPAA regulations. I also consent to being contacted via phone, email, or text for appointment-related purposes.