Dear Patient,

Please fill out the intake packet before the date of your appointment. Please also submit copies of all past testing, psychiatric or psychological treatment records, school/college records and psychiatric inpatient records/discharge summaries, if applicable.

About the evaluation
There are no standard psychological or laboratory tests by which one can make a psychiatric diagnosis. The diagnosis is made by listening to the presenting concerns, going over the records, reviewing the family and patient's history, conducting interviews with the patient, the family, and others, if necessary.

The initial evaluation will help you determine
What may be the underlying reason for the problems? Are there any psychological, medical, neurological, or genetic problems underlying the condition? Do the problems present a psychiatric disorder or a variant of normal behavior? What can be done to address the problems and what will happen if we do nothing?

The initial evaluation takes approximately one hour, sometimes longer and consists of:

1. Patient and family interview
2. Discussion of findings and presentation of diagnostic impression
3. Treatment recommendations

The evaluation will give you a good understanding of what's going on. There are many ways to deal with the problems. Many patients and the families are uncomfortable about psychiatric medications. We want you to know that medications are not always recommended and often are not even appropriate. The decision about the medication depends on the nature and severity of the problems, the patient's age, associated issues, but ultimately, on the best available treatment option.

If a medication is prescribed, you will be scheduled for follow-up appointments in one week to one month in time, depending on the problems and the prescribed medication(s).

We look forward to seeing you and hope that we can be of service.

Warm Regards,

 

Said A. Ibrahimi M.D.

Vortex Psychiatry

The office will keep a current credit card on file. I allow the office to charge fees not coverable by the insurance such as for non-coverage, yearly admin charge, unmet deductibles, unpaid copays, and no-show charges. A statement of such charges will be sent to you.

I agree to pay all bills as presented and all reasonable fees associated at the time with the collection of such charges including fees for returned checks, rush prescription, yearly admin charges, copays, phone consultation charges not covered by insurance, same day cancellation and no-show fees, request for copy of records, school form filling etc. per schedule of fees attached currently in force.

• Our HIPAA policy is posted on our website: www.VortexPsychiatry.com Please be sure to read it.

• The office staff is available to answer your call from 8 AM to 5 PM. Monday to Friday and we are available by email at vortexpsychiatry@outlook.com

• A $50 admin fee is charged yearly for all accounts. This fee is not billable to insurance and needs to be paid annually.

• We charge $200 for all changes and cancellation of appointments with less than 2 business-day notice. There are no exceptions for this (including sickness, work travel, etc.) This is a typical policy for psychiatric office where a considerable time is set aside with no double booking.

• We use an electronic reminder service for your upcoming appointment. The reminders will come via email and phone.

• You may email us about yourself or the patient if you wish. Please clearly indicate the patient’s name and date of birth and best contact number. All emails will be responded to within 2 business days. The doctor reviews emails daily in most cases. If it is urgent, please call the office instead of emailing at 925-648-2650. Standard emails are not hack proof but are considered HIPAA compliant.

• Refills are done using electronics means. This is secure and avoids errors. Please do not call the office for refills.

• Most prescription refills will require regular follow-up as suggested by the doctor. Medication refill requests must be made in writing via website or email.

• For medication refills (Schedule II medications) we require a 7-day notice. Other medications require a 3-day notice. Urgent refill requests, with less than 3-day notice will be charged a $35 rush fee.

If you will be using your medical insurance to pay for visits to this office….

•  Insurance coverage is for a particular doctor - not the office.
• If your insurance changes, let us know immediately. Transactions older than 90 days cannot be billed to insurance.
• If you have any other insurance plan, please send the superbill given to you by the office to your company. They will reimburse you directly based on your deductible and out of network coverage.
• We require a credit card on file for timely payment of amount due to this office for all unpaid charges.
• We do not verify your coverage. This is your responsibility.
• If you are seen by the doctors and your insurance deems the charges not covered, you are responsible for them.
• Please check with your insurance as to what your deductible is. During the first quarter of the year, you are expected to pay the contracted rate at the time of service. We require full payment of agreed upon rate at time of visit if you have not met your deductible.
• Phone consultations over 10 minutes are charged. Your insurance most likely will not cover these.
• Some services such as phone consultations with other providers, review of records, no-show charges, cancellation fees, form filling, reports etc. are often NOT a reimbursable expense. If these services are used or requested by you, you are responsible for their charge.
• If after billing your insurance company we find that you do not have coverage, have not met the deductible, or for any other reason, the amount due will be charged to your credit card on file after 30 days.
• Please call your insurance and make certain that you are covered for seeing this office, the doctor with whom you have the appointment and clearly understand your deductibles and your coverage. For purposes of meeting your deductible, please be advised that typical charges from this office may be approximately $1500 per year.

Please read carefully and sign. This is a required form if you want us to bill your insurance.

Article 1: Agreement to Arbitrate: It is understood that any dispute as to whether any medical ny medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim. However, following the assertion of any claim against the physician, any fee dispute, whether or not the subject of any existing court action, shall also be resolved by arbitration.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting ¡n the capacity of arbitrator under this contract. This immunity shall supplement, not supplant, any other applicable statutory or common law.

Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.

The parties consent to the intervention and joinder ¡n this arbitration of any person or entity which would otherwise be a proper additional party ¡n a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. 

The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Sections 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05; however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date ¡t is signed (including, but not limited to, emergency treatment) patient should initial below:

Effective as of the date of first medical services

If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of
any other provision.

I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT .

Controlled substance medications (i.e., benzodiazepines and stimulants) are very useful. However, they have potential for misuse and therefore are controlled by local, state, and federal authorities. Because my provider is prescribing such medications for me, I agree to the following conditions:

1). I am responsible for the controlled substance medications prescribed to me. If my prescriptions and/or medication are misplaced, stolen, or if “I run out early”, I understand that this medication will not be replaced regardless of the circumstances.

2). I will not request or accept controlled substance medication from any other physician or individual while I am receiving such medication from Vortex Psychiatry. Besides being illegal to do so, it may endanger my health. I understand that if I violate any of the above conditions, my prescriptions for controlled medications may be terminated immediately. If the violation involves the concomitant use of non-prescription or illicit (illegal) drugs, I may also be reported to other physicians, pharmacies, medical facilities, and the appropriate authorities.

3). I am aware that all requests for prescriptions must be in writing during business hours.

1. I am responsible for taking the medication in the dose prescribed and for keeping track of the amount remaining. Renewals are based upon keeping scheduled appointments.
2. Refills will not be made as an “emergency”. No controlled medications can be ordered when the office is closed. I understand the importance of following my treatment plan as directed by my physician and agree to keep my scheduled appointments.

4). I understand that if I violate this controlled substance contract due to non-compliance of medical directions, such as: failure in taking medications as prescribed, utilizing other illicit drugs, obtaining similar medications from others, or abuse of controlled medications, I may be subject to dismissal from this practice.

5). I understand that the main treatment goal is to improve my ability to function. I am being given potent medication to help me reach that goal and agree to help myself by following better health habits. I understand that using illicit drugs will negatively impact my progress. Continued use of illegal or illicit substances after warning can be cause for termination of medical care and reporting to authorities.

I have read this contract and fully understand its content and the consequences of violating this contract. By signing below, I accept the above treatment agreement.

Dear Patients,

This letter is to inform you of our updated billing practice regarding receiving patient payments. Effective January 2015, we now require a credit or debit card to be on file with our office or full patient payment of services at each appointment.

Why the change? There are several reasons for this change. With the changing environment in healthcare, in particular the Affordable Care Act and High Deductible Health Plans (HDHPs) more responsibility of payment is being placed on the patient. We need to be sure that patient balances are paid in a timely manner. To do this, we need to ensure we have a guarantee of payment on file in our office.

What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if your policy has a $2,000 deductible, you must pay the first $2,000 of medical expenses before the insurance company begins to pay for any services. This works just like the deductible for your car insurance or homeowner’s insurance policy does.

When do I have to pay for services? Any time you receive medical care, you will be expected to pay in full for your services until your deductible is met. If you have a very large deductible, called a high-deductible insurance plan, you may have to pay out of pocket for most of your primary care services.

How will I know when my deductible has been met? You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay if the amount went to your deductible when they send you an Explanation of Benefits (EOB.)

How will I know how much you are going to charge me? You will receive a letter in the mail (or e-mail) from your insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits (EOB.) This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay.

Then what? We receive the same Explanation of Benefits (EOB) that you do. Most Insurances will send your EOB prior to us receiving our copy. It arrives about 10-20 days after your appointment has been billed. We look at each EOB carefully and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a statement for in the mail.

All patients with commercial insurance are required to keep a credit or debit card on file. If you do not wish to keep a card on file, we will expect an estimated payment at the time of service. For example, if your commercial insurance requires $175.00 to be paid for standard service and your deductible is not met, you will be expected to pay the $175.00 via check or credit card before you are seen, but this will not include ancillary charges that may arise out of your visit. Once we receive the Explanation of Benefits (EOB) on your visit, we will send a statement if your patient responsibility is higher than the originally collected amount or you will have a credit on your account if your patient responsibility is lower than the originally collected amount.

Once we receive the insurance EOB for your visit, we will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Once charged, we will email you a receipt of payment.

The other items that can be charged are no-show charges, and unpaid copays.

Fee	Charge	Explanation
New Evaluation appointments	$460	Approximately 1 hour
Yearly admin fee	$50	Payable at first visit of the year- not covered by insurance. This is in addition to your copay.
Regular follow-ups	$200	Appointment time 15 to 30 minutes
Longer follow up appts	$340	Appointment time 30 to 40 minutes (complex)
Failed or cancelled appointment charge	$75-$200	All changes and cancellations less than 48-hour notice
Rush RX refill	$35	48 hours or less to fill prescription
Copy of Records	$30	See website for more details
Letters/Forms	$50 - 150	Personal letters/forms for schools, lawyers, psychologists, airlines, etc.

*Contact information of a person completing this form if not a patient

Medications:   Please list all current medications, including vitamins and supplements

Please rate these behaviors:  0 – Never (None)    1 – Sometimes (Mild)    2 – Often/Always (Severe)

(circle the most appropriate number)

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Message to our patients about Arbitration

The attached contract is an arbitration agreement. By signing this agreement, we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates, and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both healthcare providers and their courts. Arbitration agreements between patients and physicians have long been recognized and approved by the State of California. By signing this agreement, yon are changing the place where your claim will be presented. You still can call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both the patients and physicians. This is because the time it takes to conduct an arbitration hearing is far less than for a jury trial. Further, both parties are spared some of the rigors of a trial and the publicity which may accompany judicial proceeding.

Our goal, of course, is to provide medical care in such a way as to avoid any such dispute. We are all caring doctors and do our utmost to be responsive. We know that most problems begin with communication. Therefore, if you have any questions about your care, please ask us.