As the medical director of this clinic, I wanted to welcome you and thank you for inquiring about an appointment at the NeuroScience & TMS Treatment Centers.
We are in-network insurance clinicians with BCBS, Anthem, United, Optum, and Cigna and accept other insurance. We are NOT in-network with Medicare nor TNCare and cannot bill for services with these insurance companies. In our clinic, we care for patients age 14 and up.
When you finish this application (10-20 minutes depending on your personal speed), we will review it to make sure we can provide the care you are seeking. If you are having problems, email our staff and we can send you a good ole-fashioned paper application.
There are points in the process where you can save your work and return to complete it later.
STEP 1: Complete this private, HIPAA compliant questionnaire and select a service
STEP 2: Complete the Insurance Section* so that we can file in-network claims & so you understand what and how your insurance will pay.
STEP 3: Read and agree to all office policies (including the Minors Policy if the patient is a minor or ward) & then, Pay the deposit** on your new patient appointment.
*If you want us to submit the claim to your insurance, you will need an electronic copy/photo of the subscriber's insurance card (front & back) while completing this form. You will also need an electronic copy/photo of your driver's license to complete the application.
**The new appointment deposit covers part of the fee for the potential of a Missed Appointment, or Late Cancellation as our clinicians set aside significant time for the new patient appointment. Insurance does not cover for Missed appointments or Late Cancellations, see the policies below. If you come to your scheduled appointment and your insurance covers your visit fees, we will reimburse (or credit your account) for any amount which you may have overpaid.
Prior to your initial appointment, we will ask you to fill out another Medical History questionnaire.
We look forward to helping you with the process of reaching wellness. If you have questions about the process, email our Front Office Manager, Whitney Patton, email@example.com.
Michelle Cochran MD, DFAPA, Medical Director Diplomate of the American Board of Psychiatry & Neurology Distinguished Fellow of the American Psychiatric Association Past President of Clinical TMS Society
The Custodial Parent or Legal Guardian should REVIEW AND SIGN this Consent to Treat Minor IF Patient is under 18 years of age or has a legal guardian.
If the patient is under the age of eighteen or unable to consent to treatment, a legal custodian of the Patient will be required to authorize and consent for the initial evaluation and on-going treatment on behalf of the Patient.
I voluntarily consent that my child, or ward, will participate in a mental health evaluation (e.g. psychological or psychiatric) and/or treatment by staff from the NeuroScience and TMS Treatment Center. The evaluation and treatment will be made by a licensed mental health clinician (a psychotherapist, psychologist, psychiatric nurse practitioner, psychiatrist, or licensed therapist). I understand that following the evaluation and/or treatment, complete and accurate information may be provided concerning each of the following areas:
1. The benefits of the proposed treatment 2. Alternative treatment modes and services3. The manner in which treatment will be administered4. Expected side effects from the treatment and/or the risks of side effects from medications (when applicable).5. Probable consequences of not receiving treatment 6. Expectations regarding the length and frequency of treatment
It may be beneficial to my child, or ward, as well as the referring professional, to understand the nature and cause of any difficulties affecting my child’s, or ward’s, daily functioning, so that appropriate recommendations and treatments may be offered. Uses of this evaluation include diagnosis, evaluation of recovery or treatment, estimating prognosis, and education and rehabilitation planning. As a parent or guardian of the patient seeking evaluation and treatment, I may have useful information for the professionals doing the evaluation and ongoing treatment, because of this fact, please disclose all information which can be helpful to the treatment team at any point in the care process. Information can be given verbally, or in written communication.
Treatment will hopefully give benefits, which may include improved cognitive or academic performance, emotional and physical health status, quality of life, and awareness of strengths and limitations.
Fees are based on the length or type of the evaluation or treatment, which are determined by the nature of the service. As the parent or guardian of the patient, I will be responsible for charges. Fees are available to me upon request and may be referenced in the new patient packet.
Information from my child’s, or ward’s, evaluation and/or treatment is contained in a confidential medical record at the NeuroScience and TMS Treatment Center, and I consent to its use by staff for the purpose of continuity of my child’s, or ward’s, care. Per Tennessee mental health law, the information provided will be kept confidential with the following exceptions: 1) if my child, or ward, is deemed to present a danger to himself/herself or others; 2) if concerns about possible abuse or neglect arise, or 3) if a court order is issued to obtain records.
I have the right to withdraw my consent for evaluation and/or treatment of my child, or my ward at any time by providing a written request to the treating clinician. I have read and understood the above, have had an opportunity to ask questions about this information, and I consent to the evaluation and treatment of my child or my ward. I also attest that I am the legal guardian and have the right to consent for the treatment of this child or ward. I understand that I have the right to ask questions of my child’s, or my ward’s service Clinician about the above information at any time.
Under your health plan, which you selected above, you are financially responsible for co-payments, co-insurance, and deductibles for covered services, as well as those services that exceed benefit limits.
You are also financially responsible for all non-covered services as defined by your health plan contract. For example, this may include items such as specific services, supplies, vitamins, or durable medical equipment.
The services or products listed below are not covered according to your healthcare insurance plan. Your acknowledgment below indicates that you have been advised of this information and that you agree to pay for the listed services or products.
Reason (Identification of Prescribed Service/ Modalities/ Procedures):
1. Charges for Late Cancellation of New Patient Appointment (failure to cancel within 3 business days) or Missed New Patient Appointment (Doctor/Nurse Practitioner: $395)
2. Charges for Late Cancellation or Missed Follow-up Appointments (Doctor $250 for 30min/$350 for 60min; Nurse Practitioner $120 for 30min/$200 for 60min)
3. Refills outside of office visits ($30)
4. Phone Calls, Emails, Letters, Review of Tests/Labs, Coordination of care; Pro-rated at cost of Clinician's time (Doctor $250 for 30min/$350 for 60min; Nurse Practitioner $120 for 30min/$200 for 60min)
I have been informed that my health care benefits insurer or the administrator has determined that the above-referenced service(s) will NOT be a Covered Service.
My health care benefits insurer or administrator may determine that any of the above charges are considered Non-Covered, an Investigational Service, Cosmetic, or may not be Medically Necessary or Medically Appropriate as those terms are defined in my Member Health Care benefits plan. Therefore, the service would be excluded from coverage by my health care benefits plan. My clinician has also informed me about alternative treatments, if any, that may be covered (scheduling regular visits to avoid outside charges, scheduling appointments to avoid emails, phone calls, paperwork and refills); I have also been told that I may see a different clinician or clinic who may have different office policies.
I understand that my clinician may request that my healthcare insurance reconsider that determination by presenting evidence that the referenced services(s) are not an Investigational service, is a covered service or the service is considered to be Medically necessary or Medically Appropriate. I also understand that I have the right to request a reconsideration of that determination, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s).
I have been informed of the potential costs of the service(s) that will be referenced above. I understand that, if I elect to receive the services(s) and my healthcare insurance company determines that the service(s) is an investigational Service, is not a Covered Service or the service is not considered to be Mentally Necessary or Medically Appropriate, I will be responsible to pay for all the costs associated with the service(s), including, but not limited to, practitioner costs, facility costs, ancillary charges, and any other related expenses. I acknowledge that my healthcare insurance company will not pay for the services(s).
I understand that I have the right to request a reconsideration of the determination by my healthcare insurance plan, as described in the Member grievance section of my health care benefits plan, either before or after receiving the service(s).
I will be responsible to pay for all the costs associated with the service(s), including, but not limited to, Clinician/practitioner costs, facility costs, ancillary charges, and any other related expenses.
This form's time frame is from the date of execution through December 31st, 2025.
Schedule/details: per occurrence
Clinic: NeuroScience & TMS Treatment CentersClinician Signatures on-file: Michelle Cochran, MD; Mary Phillips, APRN; Susan Swanson-Moore, APRN
The policies, below, are highlighted for emphasis:
****Read ALL the Policies (Privacy, General Office, and Insurance & Payment Policies), on the website, www.hopeforyourbrain.com, then sign below.****
Late Cancellation/Missed Appointment Policy
Notification must be received by 4:00 pm CDT, three (3) business days before the scheduled appointment in order to avoid charges.
If you have to cancel or reschedule my new patient appointment, you must give three (3) business days notice prior to the date of the appointment in order to receive a full refund. A large block of time is booked for the new appointment, and we must have a 72-hour (three business-day) notice in order to potentially reschedule the time. If you cancel the new patient appointment or miss the appointment you will be responsible for the full-fee ($395) and this can not be billed to insurance. We will use your deposit for part of this late cancellation/missed appointment but you will still owe $220 more (Total charge $395 - deposit $175 = Remaining balance of $220).
For all follow-up appointments, we also have a 72-hour cancellation policy. If you miss an appointment OR do not cancel with a three (3) business-day notice, you will be obligated to pay the full fee of the service. The Late cancellation or missed Nurse Practitioner session/30-minute appointment would cost $120/a late cancel or missed Nurse Practitioner session/30-minute appointment would cost $200.
Again, Late Cancellations and Missed Appointment fees are not covered by insurance.
Prescription Refill Policy
The policy in the office is to refill all medication within an appointment, and because of this we generally, do not prescribe medication outside office visits.
Medication refills are handled during office hours, during scheduled appointments, when an assessment can be made of the patient. We refill medications only for patients currently under in our care.
If you are prescribed medication, you will be given enough medication to cover you until your next scheduled appointment. If you have to cancel please reschedule quickly to avoid running out of medication. Contact us directly if you need a refill of prescribed medication, and allow 72 hours for refills to be sent.
Prescription refills outside of an office visit will be charged $30. This fee is not billable to your insurance.
If your appointment is rescheduled because of unforeseen circumstances, on our part, there will not be a charge.
Payment of Charges Policy
All charges must be paid at the time of service. The office staff will collect for the booked amount of time with the Clinician (or co-pay and deductible if applicable).
You are agreeing to allow Neuroscience & TMS Treatment Centers (NS-TMS) to charge the credit card on file for any fees due that are outstanding following the appointment or outside of an appointment.
The following are a few common examples of when this might happen:
• If you have insurance coverage for your appointments and we incorrectly collected a lower estimated co-pay, co-insurance and/or deductible, and then later receive an Explanation of Benefits (EOB) from your insurance showing that we did not collect enough money from you, then we will notify you and charge the balance to your card on file.
• If your appointment goes beyond the originally booked time, then the clinician will bill for the additional amount of time in the session, and this could mean that you might have a larger charge than you paid when you arrived for the appointment.
• The clinicians charge their hourly rate for any service on your behalf (letter writing, review of medical records, calls to outside therapists/or clinicians caring or you, review of labs/tests, completing special insurance forms, emergency call after hours, refills outside of your appointment, late cancellations/no-show charges, etc.).
Likewise, if we overcharge you, we will immediately apply the credit to your account. If you prefer, notify us and we can refund the charge.
By signing below, I am acknowledging that I have read all of the policies on the NeuroScience & TMS Treatment Centers website.
I agree to my cardholder policy and I authorize the $175.00 deposit, as well as, all outstanding fees, non-covered fees, and late cancellations or missed appointment fees to be charged to my credit card as explained in the Insurance & Payment policies and the General Office policies.
I have read & agreed to all policies of the NeuroScience & TMS Treatment Centers (Privacy, General Office, and Insurance & Payment) and any and all of those policies that may be amended and published on www.HopeForYourBrain.com.