This copy of the office policy is for viewing purposes only. If you are a new patient, please print out a copy of the office policy under "New Patient Forms" and bring it with you for your first visit.
OFFICE HOURS: 8:30am – 4:30pm Monday through Thursday and 8:30am – 2pm on Fridays.
APPOINTMENT CANCELLATION POLICY: When you schedule an appointment with us, that time is specifically reserved for you and you alone. If you miss an appointment without calling to cancel or reschedule at least 24 hours ahead of time you will be charged $65. The only exception to this fee is if you can provide documentation you were hospitalized. You will be charged a no-show-fee if you arrive late and have to be rescheduled for another day. If you come to your appointment without canceling ("no show") you will be required to provide a credit card number in order to schedule another appointment. On the second "no show" or less than 24 hour cancelation, the missed appointment fee will be collected. Please note that although we do offer courtesy email, text message, and phone call reminders, the patient is responsible for remembering his/her appointment. Not receiving an appointment reminder will not be considered an excuse for missing an appointment. Insurance companies to not reimburse for these fees. After two no shows you may no longer be able to be seen in our clinic.
PRESCRIPTION REFILLS: Prescription refills consume a surprisingly large portion of staff time. There is a small fee (see Physician Ancillary Charges below) for refills given and refills may be denied due to missed or overdue appointments. To help ensure safety and well-being, patients are expected to follow-up within the time frame recommended by their provider. Prescriptions will be given at each appointment with enough refills to last until the recommended time of your next appointment. If you refills are running low, it likely means it is time to schedule a follow-up appointment. BEFORE CALLING OUR OFFICE TO REQUEST A REFILL, PLEASE CHECK YOUR BOTTLE OR CALL YOUR PHARMACY TO SEE IF YOU HAVE ANY REFILLS REMAINING. PLEASE ALLOW AT LEAST 48 HOURS FOR REFILL REQUESTS. NO REFILLS WILL BE GIVEN ON FRIDAYS.
FEES: There is a $25 charge for returned checks. Balances over 90 days may be sent to a collections agency. Medical record fees are $15 plus 65 cents per page.
PHYSICIAN ANCILLARY CHARGES: It is in the patient's best interest to have as much communication as possible in person as this increases the safety and efficacy of treatment. Insurance companies do not reimburse the fees listed below and therefore patients are responsible for all accrued charges. WITH THE EXCEPTION OF SIGNIFICANT MEDICATION SIDE EFFECTS OR AN EMERGENCY, PLEASE DO NOT ASK YOUR DOCTOR TO CHANGE MEDICATION OVER THE PHONE. If you think your medication isn't working or would like to discuss treatment options, please schedule an appointment. This helps ensure optimal patient care.
• Telephone and e-mail consultation $10 each 5 minutes
• Emergency calls after hours $15 each 5 minutes
• Prescription refills due to overdue appointment $10 per prescription
or replacement of lost prescription
• Reports/letters/consultations $10 per page
DRUG SCREENING: In accordance with prescirbing guidelines, any patient may be asked to submit a urine sample for drug screening at any time. Failure to comply with the test may result in the patient no longer being prescibed his/her medications. The purpose of druge screening is to confirm medication adherence, reduce diversion of medications, and to prevent accidental overdose due to overusing prescribed medications or drug-drug interactions.
PRIOR AUTHORIZATIONS: If a prior authorization is required for a medication, it is the responsibility of your pharmacy to notify our office. It is important we have your current insurance information on file. After we submit the required paperwork, unsurance companies can take up to one week to make a decision. We cannot call insurance companies for approval during this waiting period. We appreciate your patience and will notify you as soon as a decision has been made.
INSURANCE: As a service to our patients, claims for visits are submitted to your insurance company by a contracted vendor. Our office will make every effort possible to obtain accurate information about your insurance benefits including limits of coverage, deductibles, and co-payments. You are responsible for all charges not covered by your insurance. Payment is required in full at time of service. Your physician's referral and verification of insurance benefits by our office are not a guarantee of insurance coverage. We recommend you contact your insurance company to ensure that you understand your coverage and to ensure you have coverage for mental health services. Do not assume that you will not owe anything if you have more than one insurance policy.
CONFIDENTIALITY: Information regarding your treatment will not be released unless these is prior written consent, indication that clear and immediate danger to self or others exists, certain legal circumstances required by law, or disclosure of neglect or sexual or physical abuse of a child under the age of 18 or members of vulnerable populations.
AUTHORIZATION TO RELEASE INFORMATION: I authorize Tricounty Behavioral Health to release information about me to my insurance company and the professional who referred me. This information is protected under the Privacy Act, the Drug Abuse Office and Treatment Act and the Comprehensive Alcohol Abuse & Alcoholism Prevention & Rehabilitation Act.
INFORMED CONSENT/ACKNOWLEDGEMENT OF UNDERSTANDING AND AGREEMENT: I consent to have Tricounty Behavioral Health perform or order clinical assessments, psychotherapy, provide consultations, recommendations, and/or related mental health treatment. I have read all of the information listed above regarding policies and procedures. My signature below indicates my understanding and agreement.