Practice Policies | Payments

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Cancellation Policy:
No shows, cancellations, or rescheduling an appointment with less than 24 business hours notice will be responsible to pay a fee of $50.

For example:

Our office is open Monday through Friday of each business week.

If an appointment is on Tuesday at 10am, you will communicate any changes no later than the day before, Monday by 10am.

If you, or your child's appointment is on Monday at 4pm, you will communicate your cancellation no later than the Friday before that weekend at 4pm. (Business hours apply.)

If you do not reschedule or notify us of changes to an appointment time or date, as agreed to in the above terms, the credit card you have on file will be charged the $50 late cancellation/no-show fee.

##Cash Payment Policy

Initial intakes are mandatory for care.

You agree to pay professional fees as follows:

| Psychiatric Intake (PMHNP) — required to begin care | 60 min | $275 |
| Therapy Intake (LCSW/LMHC/LMFT) — required to begin care | 60 min | $175 |
| Comprehensive ADHD Evaluation (PMHNP) — see below | multi-visit | $550 |
| Medication Management (short) | 15 min | $70 |
| Medication Management (extended) | 30 min | $115 |
| Ongoing Therapy | 60 min | $150 |

## Comprehensive ADHD Evaluation

The Comprehensive ADHD Evaluation is a flat-fee package of $550, charged in full at the time of scheduling. It includes:

1. A 60-minute diagnostic intake with a psychiatric nurse practitioner
2. Standardized ADHD rating scales and any additional testing your provider determines is clinically indicated
3. A written summary of findings, diagnosis, and treatment recommendations
4. A 30-minute follow-up visit to review results and discuss next steps

Please note the following:

* The $550 fee is the same whether or not additional testing is indicated. Your provider will determine what testing is appropriate based on your clinical presentation.
* This fee purchases a clinical evaluation. It does not guarantee any particular diagnosis, and it does not guarantee that medication will be prescribed. The fee is non-refundable regardless of the outcome of the evaluation.
* The written summary provided with this package documents your diagnosis and treatment recommendations for clinical purposes.
* Any visits beyond those listed above, including ongoing medication management following your evaluation, are billed at the standard rates listed in the fee schedule.

## Charges Outside of Session Time

You agree to pay for any time spent in your, or your child's care outside of session time on a prorated basis (unless otherwise detailed above). Unfortunately, insurance companies typically do not reimburse for this. Some examples include, but are not limited to:

* Phone calls, messages in the patient portal, voicemails, letters, video sessions and texts between us and: you, your child, or other physicians, therapists, teachers, family members, insurance companies, etc.
* Prescription refills outside of session time
* Time spent obtaining prior authorizations
* Coordination of care for emergencies, hospitalization, intensive outpatient, residential treatment, rehabilitation, etc.
* All forms (insurance, worker's compensation, school, employer; doctor's notes, letters, or reports) and chart reviews not filled out in session
* Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority

Additional charges:

* There is a $50 fee for returned checks (which will also result in your credit card automatically being run for the balance due) and for credit card chargebacks that are unsubstantiated.

You are financially responsible for all charges, whether or not:

* Insurance pays for any services
* We decide to proceed with treatment
* Treatment is successful, for which there cannot be any guarantee

## For In-Network Providers

For in-network services, we will submit claims on your behalf as a courtesy, but there is no guarantee that your insurance will pay.

You are responsible for full payment, whether your insurance company ends up paying partially, or not at all, for services rendered.

You affirm you are an authorized user of the credit card whose number and expiration date are supplied, and you do authorize its use for all fees incurred.

By typing your signature below, you confirm you have read the above and agree to these terms and conditions.

I have read and understand the information provided above regarding Tele-psychiatry. I have discussed it with my provider and all of my questions have been answered to my satisfaction. My signature below affirms that I hereby give my informed consent for the use of Tele-psychiatry in my health care and authorize my provider to use Tele-psychiatry in the course of my diagnosis and treatment.

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