Treatment Consent and Acknowledgement
Brazos Valley Psychiatry offers quality psychiatric services. Effective and efficient provision of treatment requires the following policies to enable these processes:
Financial Policy: All co-payments, self-pay amount and past due balances are due at time of check-in. We accept cash or credit cards. Patient is responsible for verifying network status, copay amount and deductibles. Patient will be fully responsible for the visit fee in the event the claim is denied. Full policy details are outlined on page 3.
Appointment Policy: A 48-hour notice for cancelation is required. Arriving more than 10 minutes late to a scheduled appointment is considered a “no-show” and will need to be rescheduled. If proper notice is not provided or the patient is more than 10 minutes late the patient is responsible for the “no-show” fee of $125. Full policy details are outlined on page 2.
Medication Policy: Medication refills must be requested through the online patient portal. It is the responsibility of the patient/parent to request refills prior to running out of medication. Our office does not automatically send refills every 30 days. All refill request are processed within 1-2 business days. Full policy details are outlined on page 3.
Phone Policy: Phone calls to the office may be made at any time during business hours. Phone calls made for treatment purposes may be charged a fee. Phone calls for scheduling or matters of short duration will not be charged. Phone calls are answered and returned by an office staff member or nurses, not by the physician, nurse practitioner or physician assistant. If you feel it is a medical emergency do not call the office first—call 911 or visit the closest emergency department.
Telehealth: Our office uses technology to increase patient engagement and improve clinical care between visits. This technology allows for secure communication (including video visits) between the office staff, patient and doctor. It also allows for the office staff to remotely monitor symptoms with the ability to trend data to aid in clinical decision support. You understand this technology will be used in your care or your child's care.
Prescription Drug History: A review of your prior prescription drug history will be completed from other healthcare providers, Texas PMP (Texas Prescription Monitoring Program) and/or third-party pharmacy benefit payors for treatment purposes. Full policy details are outlined on page 3.
Acknowledgment of Receipt of Privacy Notice: I have been presented with a copy of Brazos Valley Psychiatry Notice of Privacy Policies, detailing how my information may be used and disclosed as permitted under federal and state law.
Insurance Release: I hereby authorize Brazos Valley Psychiatry to release to my insurance company or its representative, any/all information requested to include my diagnosis and records of my mental health treatment by this practice. I also authorize and direct my insurance company to pay directly to Brazos Valley Psychiatry the amount due for treatment and/or services rendered. Patient/Insured agrees to pay for any/all services that are denied by the insurance company as not medically necessary, etc.
Furthermore, I hereby give consent to Brazos Valley Psychiatry to render mental health services deemed necessary for myself and/or minor child as designated in the treatment plan.