PLEASE RETAIN THIS NOTICE FOR YOUR RECORDS
Scheduling and Cancellations — Please note that psychotherapy sessions are typically 45-50 minutes long, and psychiatric medication management visits are typically 15-30 minutes long. New patient appointments/evaluations for both psychiatric/psychotherapy services are 1 hour. While our office does make every effort to assist patients with scheduling and appointment reminders, please keep in mind that the patient is ultimately responsible. Appointments not cancelled within 24 hour notice in non-emergency circumstances will be subject to a $150 no show fee, which cannot be billed to the patient’s insurance company and will be the patient’s sole responsibility.
Payments – Payments for all services are required at the time of service. This includes insurance co-pays, debuctibles, no show fees, and any additional patient balance responsibility not covered by your insurance policy.
Emergencies — In the event of a clinical emergency, patients may contact their provider via phone. If a provider is not available in case of emergency, please call your local crisis line, contact your primary care physician, your local health department, or proceed to your local emergency room. Call 911 in immediate matters of personal safety. We do have an answering service available when the office is closed. Non-emergency patient requests/communication are typically handled via email or our office staff; please speak to your provider regarding communication preferences.
Prescriptions – If your treatment plan includes psychotropic medication, we request that all patients speak to their psychiatrist regarding their upcoming prescription needs in person during your appointment, and be sure that they have the necessary prescriptions to last them until their next scheduled appointment. In the event that you need an additional copy of your script or a refill prescription in between appointments, there is a $15 refill charge, as your request requires office personnel to process. To avoid this charge, make sure you receive enough refills when you see your doctor. The $15 fee also applies to controlled substance prescriptions that have to be re-written. Also, if the patient has not been seen by an Elemental Center provider within the past three months, we will be unable to process your prescription refill request until the patient is seen in office for an appointment.
Confidentiality – We are committed to making this a safe place for you to get help. To that end, we adhere to all legal protections of your confidentiality. Limitations include staff consultation, life-threatening behavior, child abuse, elder abuse, and judge’s orders to release information.
Authorizations – Patients seeking services at the Elemental Center authorize the following:
1..I authorize the release of information to my insurance company(s).
2. I authorize direct payment to my service provider.
3. I understand that it is my responsibility to pay any deductible, co-insurance amount or any other balance not paid by my insurance, for services provided. This payment is expected no later than 30 days after receipt of billing information from this office.
4. I understand that it is my responsibility to pay any co-pay the day and time services are provided.
5. I understand that there will be a service charge on all returned checks.
6. I understand that if my account is sent to collection a collection fee of 33% will be added to the
total owed when sent to collection. All attorney fees and court costs incurred by the creditor will be the responsibility of the debtor.