Policy Agreement

Policy Agreement

Victoria Martin, M.D.
All patients must complete our information forms before seeing the doctor.
Patient's Name*

First NameLast NameSuffix
Date of Birth*
General Consent
I hereby give my consent for medical/psychiatric treatment by Victoria Martin, M.D.*

Yes
Release of Information and Contact
The patient or guardian of that patient must sign an individual Authorization for the Release of Information form for each person, professional or entity requesting any verbal or written communication pertaining to patient's treatment before Dr. Martin will release said information.*

I understand
Messages may be left for the patient about appointment reminders or instructions regarding their care at the phone numbers and/or email addresses designated on the New Patient Enrollment form. You must update Dr. Martin's office if and when contact information changes.*

I understand
Financial
Adult patients are responsible for full payment at time of service. The adult accompanying a minor and the parents (or guardians) of the minor are responsible for full payment at the time of service. Any minor under the age of 16 will not be seen unless accompanied by an adult.*

I understand
Regarding Insurance
We will provide you with documentation from each visit to assist you in filing your claims. Dr. Martin does not accept assignment of benefits and no longer participates in any network. Your insurance plan will reimburse you directly. Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. We have no agreements to offer discounts for specific plans.*

I understand
Cancelled and Missed Appointments
Any cancellation, within 24 hours of an appointment, will be subject to a "Late Cancellation Fee", equal to 50% the appointment fee. (Extenuating circumstances will be considered)*

I understand
Any missed appointment, without cancellation or notification to our office (AKA "no-show"), will be subject to a "No-Show Fee", equal to the full appointment fee.*

I understand
If late cancellations and/or missed appointments become a recurring pattern, Dr. Martin reserves the right to refuse future appointments.*

I understand
Confidentiality
Dr. Victoria Martin's office is fully compliant with current HIPAA guidelines. A copy of our Notice of Privacy Policies/HIPAA statement is available upon request from our receptionist.*

I understand
Your signature specifies that you have read all of the above and that you understand and agree to be bound by all policies contained in this document.
Date of Signature

MonthDayYear
Name of Signee (Patient or Legal Guardian)

First NameLast Name
Signature of Patient or Legal Guardian:*

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Policy Agreement

Release of Information and Contact

Financial

Regarding Insurance

Cancelled and Missed Appointments

Confidentiality