I understand I am responsible for all charges incurred for professional medical/mental health services provided for me or my dependent, regardless of insurance coverage. I authorize direct payment of any benefits to Beautiful Minds Medical, Inc. from my insurance company, health plan, third-party payor on any intermediaries.

I authorize Beautiful Minds Medical, Inc. and Daniel L. Binus, MD, to release medical records and/or information to representatives of my insurance company/ health plan/third- party payor or any intermediary for the purpose of processing my medical/mental health claims or obtaining benefits. In addition, I authorize Beautiful Minds Medical, Inc. and Daniel L. Binus, MD, Inc. to release medical information to other providers for the purpose of specialist referrals and/or other continuing care.

2.) I wish to be contacted in the following manner:

Medication Refills

Please request medication refills via our Patient Portal, or by having the pharmacy contact us. Please allow at least three working days for refill requests to be processed.

 

Billing and Payments

Copayments and for office visits are due at the time of your visit. The amount of your copayment or co-insurance is determined by your health plan or insurance coverage. Payment for non-covered services is due at the time you receive the service.

We are a Medicare Participating Provider. We accept assignment and will bill Medicare for you. Please be prepared to pay your deductible and co-insurance amounts at the time of your visit. You are responsible for any charges not covered under the Medicare Program.

If you have private insurance, and insurances that we contract with, we will bill your insurance company for you. We accept assignment of benefits; however, you are responsible, at the time of the visit, for any deductibles, co- insurance amounts, and charges not paid by your insurance. We do our best to verify your health plan or insurance coverage and limitations, but you are responsible for keeping us up to date on any changes to your plan or policy.

If your visit is related to an injury or illness suffered at work, or an automobile accident, please inform our receptionist immediately.

Patients with no insurance or who are unable to provide insurance information are required to pay for services when they are rendered. Beautiful Minds Medical accepts cash, checks, certain credit cards and ATM cards.

There will be a charge of $30.00 for each returned check. Beautiful Minds Medical reserves the right to request payment by cash, credit card or debit card from any patient with two or more returned checks in any twelve month period.

You will receive a monthly statement from our office monthly indicating any balance due. Payment of the balance is expected within 10 days after receipt of the statement. Patients with unpaid personal balances may be asked to reschedule their appointment until the balance is paid.

Please inform us of any change to your name, address, telephone number, or your employment. Please discuss any questions or special circumstances with our Receptionist.

Refunds for credits on your account will be made to you or your health plan or insurance company, by check, to the address we have on file. Refunds may take up to four weeks to process.

 

Missed Appointments

We will attempt to contact you two working days in advance to confirm your appointment. Please contact us at least two working days prior to your appointment if you must cancel a scheduled appointment.
If you do not cancel your follow-up appointment at least one working day in advance, you will be charged a Late Cancellation fee of $55.00. If you miss a scheduled follow-up appointment, you will be charged a $110.00 missed appointment fee.

If you have more than one missed appointment with no cancellation notice, we will require your credit card information, and will automatically charge your credit card for future missed appointment.

 

Late Arrivals
If you arrive more than fifteen minutes late for your appointment, you may be rescheduled for a different time and date, and you will be charged a missed appointment fee.

 

Forms Completion

Beautiful Minds Medical charges a minimum fee of $50.00 for completing letters and forms. We do not complete forms for health examinations, school or sports physicals or similar examinations.

 

Notice of Privacy Practices Acknowledgment

I acknowledge that I have received the Beautiful Minds Medical Notice of Privacy Practices, with an effective date of January 1, 2019.

 

Patient Portal Consent

Beautiful Minds Medical offers patients access to their providers and certain information through our Patient Portal, available at http://www.beautifulmindsmedical.com. The patient portal is the fastest and most convenient way for you to communicate with your provider between appointments. To receive access to the Patient Portal, we must have your email address.

agree to: 

1. Attend when my appointment indicates, unless I’m unable. In that case, I will contact Beautiful Minds Medical 24hrs in advance, unless circumstances indicate otherwise. In that case, I will call as soon as I am able to cancel or reschedule. 

2. Arrive on time for all appointments.

3. Cooperate with staff and participate, to the best of my ability, in all activities and group scheduled for me.

4. Not use or possess street drugs or alcohol before or during my appointment. This is a non-smoking facility. Smoking area is in the part across the parking lot.

5. Turn my cell phone to OFF (not vibrate mode) during sessions and I will respect my time in the session by not answering calls or checking messages.

6. Refrain from making physical or verbal threats to people or property, such as name calling, put-downs, threating with objects, threatening bodily harm or property destruction.

, hereby acknowledge that I have received the Notice of Privacy Practices. Within these guidelines, at Beautiful Minds Medical, specifically there are five instances in which your right to privacy will be set aside:

A. Your therapist is required by law to report if any participant in therapy, specifically or vaguely disclose(s) information possibly indicating current or past abuse or neglect of a child, dependent adult, or elder.

 

B. Your therapist must notify the local authorities and/or the person(s) in danger if your therapist believes, from information that you disclose, that you are of danger to yourself or to someone else.

 

C. During court proceedings, the Judge’s ruling supersedes your right to confidentiality. The attorney may subpoena your records, take your therapist’s deposition, have your therapist appear in court, or all three. Your therapist must break confidentiality if the Judge makes such an order.

If I am at risk of hurting myself or others outside of sessions, I will call: