TMS New Patient Registration Form

Independent Contractor Physicians

TMS Medical of the Hudson Valley, PC ("TMS HV") contracts with independent contractors to provide care to patients. These independent contractors are not employees of TMS HV and TMS HV in no way directs, controls, or influences the care these independent contractors deliver to their patients. Specifically, as of the date of this acknowledgement, TMS HV contracts with the following independent contractor:

- Kimberly Robinson, M.D. Adult, Child and Adolescent Psychiatry, PLLC, which is owned and operated by Kimberly Robinson, MD.

By signing below, you acknowledge that you understand that the above independent contractor who may provide you care is not an employee of TMS HV and that TMS HV does not direct, control, or influence the care that they provide to you.

Informed Consent for Treatment

I agree and consent to participation in the health care services offered and provided by TMS Medical of the Hudson Valley, PC or Kimberly Robinson, M.D. Adult, Child and Adolescent Psychiatry, PLLC.  I understand that I am consenting and agreeing only to those services that the above provider is qualified to provide within the scope of the license, certification, and training of the health care providers directly supervising the services received by the patient.

If the patient is under the age of eighteen (18) or unable to consent to treatment, I attest that I have legal custody of this individual and am legally authorized to initiate and consent to treatment on behalf of this individual.

Notice of Privacy Practices

Linked here is our Notice of Privacy Practices. By signing below, you acknowledge that you have read, understand, and agree to TMS HV's Privacy Practices.

TMS MEDICAL OF THE HUDSON VALLEY'S FINANCIAL POLICY

 

1.Transcranial Magnetic Stimulation ("TMS") therapy is provided by TMS Medical of the Hudson Valley, P.C. ("TMS HV" The cost for TMS therapy may vary depending on the treatment protocol prescribed for you. TMS HV's standard fee schedule is $950.00 per unit for Initial Motor Threshold, $750.00 per unit for TMS treatment, and $900.00 per unit for Repeat Motor Threshold

2. The typical course of treatment is 36 sessions. Additional treatments may be required for maximum benefit.

Insurance Coverage for TMS Therapy:

1. Many insurers provide coverage for TMS therapy based on specific conditions and treatment protocols and often require prior authorization before beginning treatment. While our team can assist in obtaining prior authorization for treatment, it is ultimately your responsibility to verify insurance benefits and determine if you have coverage based on your diagnosis and particular benefit plan. Please be aware that authorization only determines that the requested service is medically necessary and does not guarantee payment of benefits or that your insurance will pay the full amount of TMS HV's charges. Payment is also subject to the terms of your health plan at the time services are delivered and benefit limitations and/or exclusions. You are responsible for all TMS HV charges for your care.

2. To the extent TMS HV has reached an agreement with your insurance company regarding your treatment - either because TMS HV is in-network with your insurance company or because TMS HV has reached a separate agreement regarding your TMS treatment - you hereby authorize TMS HV to bill your insurance company for those services and for your insurance company to pay such sums directly to TMS HV. If your insurance company remits such payment to you directly, you shall redirect such payment to TMS HV as soon as possible.

3. For self-pay, out-of-network, and off-label care, payment is due in full at the time of the initial course of therapy. If your insurance carrier approves coverage of TMS therapy, we will collect any copayments, coinsurance and deductibles required under your insurance plan based on ouractual charges. Please be aware that our charge to insurance may differ from our charge for self-pay patients and the amount your insurance company approves may differ from our actual charge. You are responsible for payment of our actual charge.

4. If coverage of TMS therapy is denied and you would like to appeal the denial, your insurance carrier may require a letter of medical necessity. We will provide you with a letter upon request.

Cancellation Policy

1. In order for TMS Therapy to be effective, it should be performed on a routine basis for the complete treatment protocol of approximately 36 sessions. For self-pay patients, we will refund payment ONLY if we receive notice of cancellation at least seven (7) days before the date your initial (acute phase) treatment is scheduled to begin. No refunds will begiven within seven (7) days before you are scheduled to start the initial, acute phase,

2. Missing any treatment could affect your response to TMS and is not advisable. If you fail to cancel a particular day's TMS treatment within 24 hours of that treatment, you will be charged a cancelation fee of $50.00. TMS HV, in its sole discretion, may choose to waive or reduce this cancellation fee, however, any waiver or reduction in cancellation fee shall not be deemed a change in the Cancellation Policy and TMS HV reserves the right to enforce its Cancellation Policy on all subsequent missed treatments. Please be advised that most insurance companies do not reimburse for missed appointments and therefore you will likely be personally responsible for any assessed cancellation fee.

 

Payment Requirements:

1. All patients must have a valid credit card on file while undergoing TMS therapy. By signing this acknowledgement, you hereby provide TMS HV the authorization to charge your credit card for all sums owed at the time they become due, including applicable deductibles, copays, co-insurances and balance bills.

2. The patient is ultimately responsible for payment for TMS therapy. We accept most forms of payment. Payment for TMS therapy should be made to TMS Medical of the Hudson Valley, P.C. Returned checks will becharged the entire amount plus a $25 return check fee. Late payments will be charged interest at the rate of 1% per whole or partial month the payment is overdue, or 5% of the total bill, whichever is greater.

3. If you fail to timely make required payments, TMS HV reserves the right to pursue any and all means to collect outstanding payments. If TMS HV incurs any attorneys' fees and costs in its collections efforts, you shall be responsible for reimbursing TMS HV for all attorneys' fees and costs incurred to the extent permitted by law*.

*If any collections efforts proceed to court, this provision shall be interpreted as a prevailing party fee provision.

I acknowledge I have read this document and have been given an opportunity to ask questions. My questions have been answered to my satisfaction. A copy of this form has been made available to me.

Forms:

If you require legal, financial, or insurance forms to be completed by a clinician, you will be charged and billed for the time that clinicians take to fill out the requested documents.

Credit Card Authorization Form

Please complete all fields. You may cancel this authorization at any time by contacting us. This authorization will remain in effect until cancelled.

I hereby authorize TMS HV to keep my signature on file and charge the provided credit card for services rendered.