Financial Responsibility Form
Re: Financial Responsibility
I Understand that although Priyadarshan Bajpayi MD PC d.b.a Evolve Psychiatry accepts my medical insurance, and will be submitting claims for my visits to the insurance company for payment. If for any reason the claims are denied or not paid by the insurance company, I am personally responsible for final payment for any services rendered at this facility. This card I will be leaving on file will be applied to any Tele-health or phone call appointment co-pays. I understand if I plan to participate in Tele-health or phone call appointments, it is required that I leave a credit card on file to be charged at the time of every appointment.Additionally, if for some future reason I do not meet my financial obligation I give Priyadarshan Bajpayi MD PC d.b.a Evolve Psychiatry permission to charge the credit card I will leave on file, up to $350 for services rendered. I understand that if I fail to pay two or more co-pays, at the time of my visit I will not be able to be seen by my provider. Please sign as acknowledgement. Signature
PHQ-9
GAD-7
MDQ
1. Has There ever been a period of time when you were not your usual self and...
HIPPA(If you have no one you would like us to be able to discuss your treatment with enter N/A in field 1, check off the rest of the boxes, and sign.) Thank you!
(including records relating to mental health care,and treatment of alcohol or drug abuse).