CONSENT FOR TREATMENT:
By signing this form, I consent and authorize PLYMOUTH PSYCH GROUP to treat me. I understand that this could include psychotherapy, education, medication management, and procedures such as Transcranial Magnetic Stimulation (TMS) therapy. I understand that my provider is available to explain the purpose of the treatment and procedures and that I have the right to refuse the recommended treatment.
ASSIGNMENT OF BENEFITS and BILLING AUTHORIZATION:
I hereby request payments of authorized insurance benefits be made directly to PLYMOUTH PSYCH GROUP on my behalf for any services rendered to me at this facility. I consent to PLYMOUTH PSYCH GROUP releasing my health records and other information related to my health care services for payment healthcare operations purposes.
RELEASE OF INFORMATION TO PAYERS AND NETWORKS:
I hereby authorize PLYMOUTH PSYCH GROUP to release requested health records and other information related to my health care service to Medicare, its agents, my insurance company, or health maintenance organization, other payers, payer network organizations, including accountable care organizations, their contractors, third-party administrators, state medical agency or any other governmental payor as needed for payment and health care operations. Any follow up or reporting to third parties that becomes necessary due to unpaid balances on your account shall not be considered a breach of confidentiality.
PAYMENT AGREEMENT:
I acknowledge and understand that I am financially responsible for all charges relating to the service(s) rendered to my dependent or charges for services rendered. All copays, coinsurance and deductibles are due at the time of service. We accept checks, credit and/or debit cards. We do not accept cash. There is a $35 service charge for returned checks. A monthly finance charge of 1.5% is charged for balances exceeding 30 days. If circumstances require the use of a third-party collection agency, I understand that I will be responsible for payment of collection cost, attorney, and/or court fees. Any fees will be applied to the collection balance. The collection vendor may also report your delinquency to a credit bureau.
MISSED OR LATE CANCELED APPOINTMENTS:
I acknowledge that by not canceling my appointment at least 24-hours in advance or not showing up for my appointment prevents others from being scheduled. All new patients appointments canceled within 48 hours of the appointment will be placed on a waiting list and can only be rescheduled 3 months after the missed appointment. I understand a charge of $100 fee (and $150 for a TMS therapy) will be charged to my account for the missed or late canceled appointment. Further, I understand PLYMOUTH PSYCH GROUP reserves the right to terminate my care for two or more missed or late canceled appointments without giving 24-hour notice, within a 6-month period.
PATIENT’S RIGHT TO PRIVACY:
I acknowledge I have received a copy or have been made aware of PLYMOUTH PSYCH GROUP’S Privacy Practices. I understand I may request a copy of this privacy notice. By signing this form, I acknowledge that I have been offered a copy of this office’s Notice of Privacy Practices.
PRESCRIPTION REFILLS AND CONTROLLED MEDICATIONS:
For more details, please see the “Prescription Refill Policy and Controlled Management Agreement”. In general, PLYMOUTH PSYCH GROUP provides enough refills and renewed prescriptions at the time of your appointment. You are responsible to track your medication supply and have an appointment scheduled before the medication runs out. You should contact your pharmacy to submit a refill request and allow at least 72 hours (3 business days) for your request at minimum.
Other Charge You May Incur:
If we are asked to complete additional forms or reports for you there may be additional charges. These fees will not be billed to your insurance company and are pre-paid. PLYMOUTH PSYCH GROUP may charge fees for disability forms, FMLA forms, copies of medical records and other special letters or reports.