(Update effective March 30, 2020)
PLEASE READ AND SIGN THE FOLLOWING INFORMATION CONCERNING THE POLICIES OF THIS OFFICE. YOU WILL BE GIVEN A COPY FOR YOUR RECORDS.
A. INSURANCE PAYMENT ORDER
I, (the undersigned) hereby authorize Reflections of Mental Health Inc. to use my information when conducting business with my insurance company. I understand that my health information will be used, as needed, to obtain payment for my health care services from my insurance providers. This may include certain activities the Reflections of Mental Health, Inc. staff may need to undertake before my health care insurer approves or pays for health care services recommended for me; such as determining eligibility or coverage for benefits, reviewing services provided to me for medical necessity, and undertaking utilization review activities.
B. PAYMENT POLICY
You are responsible for all co-payments and/or fees at the time of service, otherwise billing fees will be incurred. If another party is responsible for your payments, please let us know prior to your visit so that we may make the necessary arrangements.
A fee of $35.00 will be charged for any return checks, along with a processing fee.
C. CANCELLATION POLICY
Appointments are scheduled according to each patient’s needs and the availability of the physician. The time of your appointment is reserved for you. All cancellations and/or rescheduling of appointments MUST be done at least 24 hours in advance. Patients, fail to call in advance to cancel their appointment will be considered a NO SHOW will incur a $25.00 cancellation/no show fee. Confirmation calls are done as a courtesy to patients; however, there are times we cannot make them. Please do not rely on our call.
D. MAINTAINING PATIENT STATUS:
In regards to mental health, it is very important that you be seen on a regular basis. At the end of each appointment, you will be given a follow-up appointment. It is recommended that you make the follow-up appointment before you leave our office in order to schedule the most convenient time for you. If you fail to keep and/or maintain follow-up appointments for a period of six month (180 days) or greater, we will conclude that you have terminated the patient physician relationship and would no longer be an active patient.
E. TERMINATION OF CARE: Dr. Samuel reserves the right to terminate the patient-physician relationship if the patient is repeatedly noncompliant with treatment recommendations despite repeated redirection and use of available resources and/or inability to maintain a therapeutic relationship due to repeated conflicts or inability to maintain professional boundaries. The termination of care will be provided in writing via certified mail along with list of treatment providers.