Form

HIPAA Compliance: In accordance with the Health Insurance Portability and Privacy Act of 1996 which requires documented proof of acceptance of the office standards of privacy, this office provides all patients with a notice of the means of compliance with these HIPAA standards. According to the HIPAA laws, a patient can specify to whom their private medical information can be shared with. It is the policy of this office that every patient must agree to allow this practice to share any necessary medical information with the following: the signed guarantor, patient's insurance company, third party administrator (insurance delegate), patient’s attorney and this practice's attorney (only when necessary). If you do not agree to these terms, you may elect to pay for all services rendered and submit your claim independently or we will gladly refer you to another office for your medical services.

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Calling In Rx/Consultations: This practice does not allow patients to request prescriptions to be called in to the pharmacy. All prescription requests MUST be made after an evaluation and co-payment paid for a brief office visit or medication evaluation.

Prescriptions for non-emergency refills will NOT be called in during non-business hours. Emergency refills will be for no more than a 48-hour supply and a visit must be scheduled the following business day. Any calls made to/from a doctor in this practice for telephone consultation and/or therapy will result in a charge for this service. I acknowledge that this is not generally is not a covered benefit by my insurance and agree to pay for these services directly forthwith.

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SEE SEPARATE CANCELLATION POLICY

Please be aware that as a medical practice, we are obligated to know of any blood-born or contagious illness you a have. I acknowledge that I have notified this practice of any known blood-born illness (i.e. HIV, AIDS, Hepatitis):

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Charges for Covered Benefits: This practice provides psychiatric services based solely on our belief in providing the finest patient care possible. As a result, at times these services may not be covered by certain insurance companies. The office will make all necessary attempts to recover reimbursement for these services directly from the insurance company. However, the patient is ultimately responsible for payment of services rendered, none the less I understand and agree that I am responsible for charges for any services not covered by my insurance company when notified in advance that the services being provided are NOT covered. I further understand that I am responsible for any collection and/or attorneys fees in the event that non-payment of   the account results on the account being turned over to a collection agency or an attorney

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I understand it is my responsibility to obtain any and all necessary authorizations in accordance with my insurance’s guidelines. I understand that my insurance does not guarantee payment regardless of authorization. Should my insurance deny payment, I am ultimately responsible for payment of services rendered. I understand and agree to make said payment upon notification either written or oral (at said office). (NA for Self-Paying Pts)

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I understand the published rates are as follows, Initial/Diagnostic Interview - CPT Code 90792 $380. Medication Management 16 to 30 Minute Psychotherapy — 99214/90836 $180.00, Full Psychotherapy over 30 minutes but under 45 minutes 90807 $250.00, Other Charges are available upon request. I am aware and hereby agree that I am responsible for any portion of my bill that is not paid or covered by my insurance (with the exception of the insurance fee- schedule reduction agreed upon by the insurance carrier). In the event that I change my insurance carrier, I understand that it is solely my responsibility to notify this office prior to any visit that would be under that insurance. I acknowledge that the practice does NOT balance-bill or charge for prescriptions and any  charges are for services rendered under valid procedures recognized by AMA/APA standards in accordance with Medicare. 

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I hereby authorize my assigned provider to provide any necessary treatment . In the event I am placed on medication I am responsible for assuring I have sufficient medication and/or appropriate quantities until my next appointment. If I should reguire prescription refills as a result of missed appointments or scheduling my visits beyond he date of my appointment, I will be responsible for charges to refill this prescription. I understand that this is not a covered benefit and is in addition to any charges for missed appointments that may apply. I understand that this notice serves as an assignment of my benefits to Dr. Mencia Gomez This assignment shall remain in effect until 1. I provide further notice that I am paying for these services in full or 2. I am no longer being treated by Dr. Mencia Gomez.