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Sickness
Sickness explanation
I authorize Broadview Psychiatry to furnish information as necessary to my insurance carrier regarding my illness and treatment and I assign Broadview Psychiatry all insurance payments for medical services rendered. I understand I am responsible for providing all necessary information to the office or submitting charges to the insurance company for payment. If I fail to provide this information, I accept the financial responsibility of payment for services rendered. This office has a cancellation policy that requires a 48 Hour advanced notice. I understand that if I cancel within less than 48 Hours notice, a charge will be made for this time reserved. This charge is not covered by insurance and not payable from any insurance company.
I______________________, herby authorize Broadview Psychiatry and Broadview Health to disclose/exchange specific health information from records for the specific purpose(s): CONTINUATION OF TREATMENT and specific information to be disclosed: ALL PERTAINING. I understand that this auhorization will expire on the following date, event or condition: ONE YEAR FROM TODAYS DATE.
Charlotte Office Phone Number: (704) 544-0050 and (704) 635-7418 We strive to provide the best care for our patiens. In order to do so, we need to make sure all our patients are aware of these policies. Please review them carefully and sign at the bottom. We thank you for your understanding and cooperation. 1. Scheduling Appointments: It i syour responsibility to schedule with Broadview Psychiatry and Dr. Onafuye or any of our other providers. We request a 48 Hour advance notice for appointment cancellation. Patients with missed appointments or cancellations occuring less than 48 Hours in advanced are billed $100 for the time that was reserved for them, which must be paid in full before any other appointments are scheduled. We reserve the right o refuse care at any time without cause or explaniation. This first encounter with us is only an assignment to determine eligibility into our practice. It does not guarantee continued care. 2. Prescription Refills: You will be given an adequate amount of medication at each visit, until the physician's requested follow-up appointment. If you miss or reschedule an appointment your REFILL MAY BE DENINED. Approved refills are subject to a $25 dollar charge. NO REFILLS WILL BE GIVEN ON WEEKENDS AND THERE ARE NO EARLY REFILLS, EVEN IF THE PRESCRIPTION IS LOST OR BECOMES EMPTY. 3. Forms/Letters: If you have forms or letters that need to be completed outside of your appointment, a form fee of $100 is required prior to completition and allow 10 business days for processing. DISABILITY FORMS WILL BE ADDRESSED AFTER THE PATIENT HAS BEEN SEEN A MINIMUM OF 3 MONTHS. Completion of such documents remains at the discretion of the physician/provider. 4. Calls For The Doctor: Questions called in for our providers will be returned AFTER all patients scheduled for the day have been seen. It will likely be after 6pm before your call is returned, and we may ask one of our staff to call withe directions for the patient. If a provider is out of the office, it may take up to 24 Hours or the next business day before you recieve a return call. 5. The following May Lead To Termination From Treatment: Repeated failure to keep an appointment without notice. Failure to pay for services rendered. Failure to follow mutually agreed treatment plan. Refusal to comply or tampering with pharmacological screening in any form. Unruly, rude or aggressive behavior or speech to any provider or employee of the practice. 6. Payment Instructions/Financial Policy: Payments for services rendered is due in full at he time of each appointment. This includes co-payments and co-insurance. If you have insurance, it is your responsibility to call your insurance company prior to your appointment to verify your benefits and learn what is covered under your plan. Your also responsible for learning if any pre-authorizations or pre-certification is required by your insurance company prior to your visit. If you have Medicaid, you must have your current card on file to see you. If you don't have a current card, you need to reschedule your appointment. Broadview Psychiatry must keep a credit card on file for appointments missed without a 48 hour cancellation by patient. If there is a missed appointment without a 48 hour cancellation notice, a fee of $100 is processed on patients credit card. Our office chargers $25 for a returned check, after which patient agrees to pay in cash for subsequent services. We will try our best to assist you in any way possible with your bills. Any balance that is over 60 days may be transfered to an outside collections agency for credit reporting. A patient that has been placed in collections must pay any prior balance owed to the practice and The COLLECTIONS AGENCY FEE and any attorney fees in cash. You allow our office and affliated agencies to contact you on any phone number provided to our office regarding medical and billing issues. 7. Consent To Treatment: I recognize that informed consent in any medical setting is an ongoing process of discussion and dialogue with my physican. I have a responsibility to see that I am adequately informed about (1) general explantions of the nature of any treatment and the reasons it is indicated for my condition, (2) risks and benefits of undertaking the treatment and (3) alternatives to any particular treatment. Psychiatry is an inexact science, as well as an art. Therefore, there cannot be any guarantees of outcome.
