Common use of Appointment Reminders Clause in Contracts

Appointment Reminders. As a courtesy to our patients, we attempt to contact you two days before your scheduled appointment to remind you of the appointment date and time. However, it is your responsibility to keep up with your scheduled appointments. If, due to technical difficulties or unforeseen circumstances, we are unable to give you a reminder, you are still responsible for keeping your appointment and will be charged for a late cancellation or no-show according to the schedule listed on the Credit Card Agreement. Please let us know how you would like to receive your appointment reminders (choose one): By telephone. Please give us the best number to contact you. By giving us this number, you also give us consent to leave a voicemail or message if you do not answer. Best telephone number: ( ) By email. Please give us the best email to contact you. By giving us this email, you acknowledge that email is not a secure form of communication and absolve us from any liability should it be intercepted, hacked, or otherwise compromised and your confidentiality broken. Best email: I do not wish to receive appointment reminders. Primary Care Physician Information: Name Address Phone How long have you been a patient of this physician? For purposes of continuity of care, may we contact your physician to let him/her know of your visit? Yes No If yes, I give permission to to send a general statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care, and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment. Patient Signature Date Acknowledgments: Please discuss any questions or concerns with your therapist. Your signature below indicates that you consent for us to treat you, that you understand and agree with the terms of the Psychological Services Agreement, and that you acknowledge receipt of the HIPAA Notice: Client Name (please print) Client Signature Date If Applicable: Parent/Legal Guardian Name (please print)

Appointment Reminders. As a courtesy to our patients, we attempt to contact you two days before your scheduled appointment to remind you of the appointment date and time. However, it is your responsibility to keep up with your scheduled appointments. If, due to technical difficulties or unforeseen circumstances, we are unable to give you a reminder, you are still responsible for keeping your appointment and will be charged for a late cancellation or no-show according to the schedule listed on the Credit Card Agreement. Please let us know how you would like to receive your appointment reminders (choose one): By telephone. Please give us the best number to contact you. By giving us this number, you also give us consent to leave a voicemail or message if you do not answer. Best telephone number: ( ) By email. Please give us the best email to contact you. By giving us this email, you acknowledge that email is not a secure form of communication and absolve us from any liability should it be intercepted, hacked, or otherwise compromised and your confidentiality broken. Best email: I do not wish to receive appointment reminders. Primary Care Physician Information: Name Address Phone How long have you been a patient of this physician? For purposes of continuity of care, may we contact your physician to let him/her know of your visit? Yes No If yes, I give permission to to send a general statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care, and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment. Patient Signature Date AcknowledgmentsACKNOWLEDGMENTS: Please discuss any questions or concerns with your therapist. Your signature below indicates that you consent for us to treat you, that you understand and agree with the terms of the Psychological Services Agreement, and that you acknowledge receipt of the HIPAA Notice: Client Name (please print) Client Signature Date If Applicable: Parent/Legal Guardian Name (please print)

Appointment Reminders. As a courtesy to our patients, we attempt to contact you two days before your scheduled appointment to remind you of the appointment date and time. However, it is your responsibility to keep up with your scheduled appointments. If, due to technical difficulties or unforeseen circumstances, we are unable to give you a reminder, you are still responsible for keeping your appointment and will be charged for a late cancellation or no-show according to the schedule listed on the Credit Card Agreement. Please let us know how you would like to receive your appointment reminders (choose one): By telephone. Please give us the best number to contact you. By giving us this number, you also give us consent to leave a voicemail or message if you do not answer. Best telephone number: ( ) By email. Please give us the best email to contact you. By giving us this email, you acknowledge that email is not a secure form of communication and absolve us from any liability should it be intercepted, hacked, or otherwise compromised and your confidentiality broken. Best email: I do not wish to receive appointment reminders. We apologize, but due to the technical limitations of our electronic health records system, we are not able to offer text or email reminders at this time. Primary Care Physician Information: Name Address Phone How long have you been a patient of this physician? For purposes of continuity of care, may we contact your physician to let him/her know of your visit? Yes No If yes, I give permission to to send a general statement notifying my primary care physician of my visit today. The information sent will be used for coordination of care, and will be limited to a brief description of the problem area and/or diagnosis, and a general outline of treatment. Patient Signature Date AcknowledgmentsImportant Information for Insurance Patients Insurance Patients: Please discuss any questions or concerns read the following information and sign the Agreement at the bottom of this page if you would like us to file insurance for you. Health Insurance Coverage If you have a health insurance policy, it will usually, although not always, provide some coverage for mental health treatment. Our office will fill out forms and provide you with whatever assistance we can in helping you receive the benefits to which you are entitled; however, you (not your therapistinsurance company) are responsible for full payment of our fees. Your signature below indicates It is very important that you consent find out exactly what mental health services your insurance policy covers. You should carefully read the section in your insurance coverage booklet that describes mental health services. If you have questions about the coverage, call your plan administrator and inquire about mental health benefits. Of course, we will provide you with whatever information we can based on our experience and will be happy to help you in understanding the information you receive from your insurance company. If it is necessary to clear confusion, we will be willing to call the company on your behalf. The practice will make two attempts to collect payment from your insurance company. If we are unable to do so, you will be responsible for the session fee. Despite our best efforts in determining your coverage, it is very common for insurance companies to pay differently than what they quoted you at the time of the first visit, deny coverage at a later date, or request a refund for funds previously dispersed. For that reason, you may receive a bill for services rendered if your insurance company does not reimburse as anticipated or requests a refund for previously paid services. Authorization for Treatment Many insurance plans require authorization before they provide reimbursement for mental health services. This authorization is typically required prior to or on the day of the first session. Our office will do everything we can to acquire authorization on the first day of treatment, but, ultimately, it is the patient’s responsibility to contact the insurance company for authorization. If the correct information is not provided at the first appointment, then this will likely delay the authorization process. Insurance companies rarely back-date authorizations, so the initial appointment and subsequent appointments may not be covered until authorization is obtained. If you have an appointment late in the day (e.g., 4:00 or 5:00), we may not be able to obtain authorization for that initial session if you wait until the appointment time for us to treat youverify your benefits. You will then be responsible for the entire cost of that session. Insurance carriers often limit the number of sessions authorized at a time. We are willing to complete any paperwork necessary to request authorization for more sessions, that you understand and agree with the terms but it is your responsibility to notify us of the Psychological Services Agreement, and that you acknowledge receipt of the HIPAA Notice: Client Name (please print) Client Signature Date If Applicable: Parent/Legal Guardian Name (please print)when your sessions are about to expire so we may request more without any gap in coverage. Failing to do so may result in your being billed for any sessions not covered.