Patient-Provider Policy Agreement

Appointment Policy
Appointments may be scheduled by phone or online. If you are unable to come to your appointment, please give at least 24 hours’ notice. If you provide less than 24 hours’ notice (or no notice), you will still be charged a $100 no show/same day cancellation fee. Copayments, if any, are collected on the day of your appointment ………………..Initial.

Routine Telephone Messages after hours, weekends, and holidays
During the weekend, after hours (5pm until 8:30am), and holidays, please only call if you have an urgent issue. We will do our best to return your phone call as soon as we can. Please note, also, that we will attempt to call twice, but we may or may not leave a message due to confidentiality reasons .…………….Initials.
Emergencies
If you have an emergency such as a serious side effect to a medication or suicidal/ homicidal thoughts, or other life-threatening conditions, please go to the nearest Emergency Room or call 911 ………………..Initials.
Reminder Calls
Reminder calls for appointments may be placed as a courtesy. These calls are not mandatory and not receiving a reminder does not mean you no longer have an appointment ………………..Initials
Prescriptions
Medication management takes place during your session. This includes prescribing new medication, renewals of existing prescriptions, and changes in medications and dosages. Medications are prescribed to last until your next appointment. If you miss an appointment, it is your responsibility to request a refill so that you do not run out of medication. Please notify the office 7 days prior to refilling your medication. We may not give a refill if we have not seen you recently and/or feel that an office appointment is clinically indicated. Please do not rely solely on your pharmacy to contact us.

If a Prior Authorization is needed, please allow 5 business days for Prior authorization to be processed.

It is the responsibility of the patient to follow up with the insurance for the status of any prior authorization ………………. Initials

Termination of Provider-Patient Relationship
We reserve the right to terminate the provider-patient relationship for any reason, and in accordance with any applicable laws. Reasons why we may terminate the provider patient relationship includes, but not limited to: provider retiring/leaving or discontinuing participation with any insurance company, disruptive or violent behavior (or the patient’s partner is disruptive or violent), no-shows, failure to comply with a recommended plan of care, including subsequent appointments, failure to make payment arrangements according to normal practices or as agreed, leaving the clinic/practice against medical advice, threaten lawsuits, abuse drugs or controlled substances, etc.

Before we terminate the patient-provider relationship, we may contact you directly in an attempt to resolve the issue in question. We may need to document the issue of concern and your response in your medication record for the sake of compliance and adequate record-keeping. Depending on the reason for termination, and when feasible, we may work with you to facilitate the transition of care to medical society or hospital referral center. We typically would not refer you to a specific physician.

If it ever gets to the unfortunate and regrettable stage when we need to terminate the patient-provider relationship, we will give you thirty (30) days to find a new provider or refer you to a medical society or hospital referral center. We shall provide you with a written letter by electronic communication or postal mail stating the reason for termination and the effective date. We may immediately (without 30 days’ notice) terminate the patient-provider relationship verbally or in writing when there is a threat or perceived threat of violence.