Clinic Policies and Financial Agreement

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Clinic Policies and Financial Agreement – PLEASE READ CAREFULLY.

Brayden Willis, DO (“Dr. Willis”) provides direct payment fee-for-service consultations and treatments at and through Northland Child Psychiatry, LLC (the “Practice”). Please make note of the following policies:

FINANCIAL POLICY

  • WE DO NOT ACCEPT INSURANCE. Northland Child Psychiatry is not affiliated with or “in-network” with any insurance companies, including Medicare or Medicaid.
  • A new patient evaluation is $400.00. This is to be paid in full at the time of booking. 50% of this is considered a NON-REFUNDABLE deposit ($200), that will not be refunded regardless of appointment cancellation status. If the appointment is cancelled or rescheduled greater than 24 hours prior to the scheduled time, 50% of the payment ($200) will be refunded. Late Cancellations or Missed Appointments will require payment in full, without refund.
  • A follow-up appointment is $250, with payment due prior to the scheduled appointment. Under some circumstances a longer follow-up appointment of $350 may be needed (if longer appointment is needed, this will be discussed with the patient beforehand).
  • Payment may only be made via credit, debit, HSA account, or cash. If using cash, payment must be received by the clinic at least the day before the scheduled appointment.
  • We require an active form of payment on file. The card may be used for payment of the following:
  •  Automatic payment on the day of the patient’s appointment (unless the patient specifies a different payment arrangement at least the day before the appointment).
  • Telemedicine appointments as the patient is not physically present.
  • Missed appointments or late-cancellations.
  • Administrative fees such as letters, forms, other administrative documents, etc.

 

CANCELLATION POLICY / LATE CANCELLATIONS

  • If needing to change your appointment, please provide at least 24 hours notice. As late cancellations do not allow for other patients to be scheduled in the appointment slot.
  • Patients who cancel later than 24 hours before their appointment are responsible for the payment of that session.
  • Patients may reschedule an appointment once their balance is paid off for the missed appointment.
  • We do not issue refunds for any rendered services.
  • For New Patient Evaluations-

The initial 50% deposit is NON-REFUNDABLE regardless of notice given. This is because a new patient appointment requires 1.5 hours to be blocked in the clinic schedule, a sizable portion of the business day. Cancellation with at least 24 hours notice will not require payment of the remaining appointment balance. But patients cancelling late will be charged the remaining balance for the appointment.

 

MISSED APPOINTMENTS (“NO-SHOW”, NON-CANCELLED)

  • Patients who do not attend their scheduled appointment are responsible for the payment of that session.

 

LATE ARRIVALS

  • A Late arrival is defined as a patient arriving 15 minutes or greater after the scheduled appointment time. And these will not be honored and will be considered a “No-Show”. As above, such instances will result in a charge for the specific service with the active card on file.

 

TELEMEDICINE/TELEPSYCH APPOINTMENTS PROCEDURES & POLICY

  • For appointments scheduled to be conducted via telemedicine, patients are asked to enter the virtual appointment by clicking the link provided in the email/text reminder 5-10 minutes before your scheduled time.
  • Regardless of whether appointment is scheduled for In-Person or Telemed, the policies related to cancellation, “no-show”, or late arrival are the same. See above for those policies.

STANDARD OF CARE

  • As part of the acceptable/expected Standard of Care, patients who are prescribed Schedule II substances are required to be seen at least every 90 days.
  • If a patient requests a script outside of the 90-day window, Northland Child Psychiatry will provide ONE courtesy script, provided the patient schedules an appointment and is informed about the 90 day standard of care for Schedule II medications.  There is a fee of $50 for a one-month courtesy script.

ACCEPTANCE OF TERMS:

TERMINATION OF CARE

I understand that Dr. Willis at Northland Child Psychiatry, LLC may terminate a patient at his discretion at any time.

I understand that three (3) missed appointments (“No-Shows”) will result in immediate termination.

FINANCIAL RESPONSIBILITY

I agree to pay ALL applicable fees for services and treatments rendered. I understand that service fees are subject to change at any time with notice to the patient, at the discretion of Northland Child Psychiatry, LLC (“the Practice”).

I also agree to be responsible for ALL costs and expenses, including court costs, attorney fees, and interest, should it be necessary for the Practice or Dr. Willis to take action to secure payment of an outstanding balance owed.

NOTICE OF NON-COVERAGE OF SERVICES

I understand the Practice is a SELF-PAY ONLY business. The Practice and Dr. Willis do not inquire or participate in any commercial, state, or federal insurance plans, including Medicare and Medicaid. As such, payment in full will be required with each visit, in accordance with the financial policy outlined above.

The Practice and Dr. Willis DO NOT GUARANTEE COVERAGE/REIMBURSEMENT of any treatment(s) rendered, including procedures, medications, laboratory tests, or whatever else may be deemed medically appropriate. I acknowledge and understand that I am responsible to pay all costs incurred even in the event that my insurance company determines that any services are not covered, excluded, or, in their opinion, unreasonable or medically unnecessary.

Furthermore, I understand and agree that the Practice and Dr. Willis advise me to obtain and keep full health insurance coverage for myself. The services provided by Dr. Willis or the Practice are not intended to replace any current or future health insurance coverage I may carry.

I understand that I should not submit any claims for any services provided or ordered by the Practice and/or Dr. Willis to Medicare, Medicaid, or any other federal payor and any such CLAIMS MAY NOT BE REIMBURSED.

Please contact our office should you have questions regarding our clinic policies and procedures.

Thank you,

Northland Child Psychiatry, LLC