Forms and Information for our Patients

New Patients Intake:

Prior to your first appointment, please fill out the New Patient Intake Form. Be Detailed.  I understand that forms are not fun, however, this is required prior to your appointment and form not completed will result in appointment cancellations or rescheduled. This intake is critical as it allows use more time to be spent focusing only on relevant issues rather than going over your history as much. Thank you for your time with this. 
Payment for Services: All clinical practice fees are due at the time of service.  If you are an insurance client, ensures that your deductibles are met prior to your services as you will still be accountable for services fees until your insurance deductible are met. This will be collected prior to your appointment.  Co-pays are collected also prior to your appointment. For our self-paying clients, we accept cash,HSA, FSA, and Credit Cards 
Insurance Contracts:  We contact with many, but not all, insurance companies. Please contact our office directly to find out which insurances we currently take. 
Out-of-Network Reimbursement: If we are out of network with your insurance company and you choose to seek reimbursement for our services, we will provide you with a monthly statement of all services received. This statement is formatted with all of the information already entered, so that all you have to do is review the information and mail it to your health insurance. No additional information or energy is needed from you. On occasion, your insurance company may be willing to work with our office to develop a “single-case agreement” whereby they pay our usual and customary fees, even if we are not in your network. 
Cancelled/Missed/Late Appointments:  Appointments scheduled and not kept, for any reason, are fully billed to you, the patient. See Fees in your intake consents.  Your insurance company will not reimburse for any portion of missed appointment(s). Cancellation notification must be given at least 48 hours before your appointment (please call the office number and leave a message). The fees for such missed appointments are the same fee as the appointment type and duration. Every client receives ample amount of reminders of their appointments.  However, when this is not possible, you are responsible for keeping the appointment and/or canceling with at least 48 hours notice. Please note the date/time of your appointment prior to leaving the office, and if you have any questions about your date/time, please contact us at 240-833-3920
Letters/Forms:  Letters and/or forms are often requested by patients (or their parents) to be sent to schools, employers, etc. You will be charged a letter-writing fee for this service, minimum of $50, depending on the complexity of the letter and information necessitated.  For letters needing to be written for more professional matters, a minimum fee of $100 will be assigned and needs to be paid prior to any letter being written. Please allow at least two weeks for this request to be processed.

Requests for Records:  Requests for records are received from various sources. Attention to these requests will only occur if the patient (or patient’s parents) completes a signed Release of Information form. Please allow at least two weeks for this request to be processed.

Telephone Calls and Emergency/After-Hours Consultation Fee:  Telephone calls are welcome, and I will respond to these as promptly as possible. There is no charge for brief calls. Calls longer than ten minutes are charged directly to you, prorated at our non-emergency rates, with a minimum of $100.

Emergency/After-hours phone calls lasting longer than 10 minutes will be charged at the rate of $100/15 minute increment, minimum $100. In an extreme or life-threatening emergency, please call 911 or go to your nearest emergency room.
Prescription Refills:  Prescriptions written during clinical sessions are free of charge.  At the end of your appointment, you will be told when you should have your next appointment and you will be given enough medications to make it to your next appointment.  If you have run out of any controlled medications, it almost always means that you are overdue for a follow-up appointment.   
* * NOTE – PRACTICE STANDARDS REQUIRE ALL PATIENTS BE SEEN IN PERSON, AT MINIMUM, EVERY 3 MONTHS.
Legal/Forensic Work:  Any legal/forensic work is performed at a rate of $2000/hour.  This includes letters for court or to attorneys, dispositions, testimonies and any other work where court proceedings are involved. Time includes the hours necessary for transportation and preparation for any legal work as well as wait time for court proceedings.  Additional billing criteria will be discussed in person.  Minimum fee is $2000 and billed in 15 minute increments.  Any testimony is at a minimum of 5 hours on the day of testimony; this is in addition to time mentioned above for preparation.  Please call for additional details.  All fees/legal work must be paid in advance by retainer with amount to be detailed on a case by case basis.
Thank You – We look forward to meeting you and discussing how we can help you!

Visit us for Telepsychiatry in Bethesda MD, Rockville, MD and Silver Spring MD and Washington DC.

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