I request treatment for myself at Open Mind Psychiatry. Services may include diagnosis evaluation and treatment for any medical, emotional, and behavioral problems which may be found to exist.

Liability

In consideration for services rendered, patient agrees to hold Open Mind Psychiatry blameless for any liability due to an accident, illness, or incident, which may occur to patient while receiving outpatient services. Patient also agrees to hold Open Mind Psychiatry free from all liability for any losses through fire or theft. Patient agrees if hospitalization or extensive medical care is needed, Open Mind Psychiatry is to assist the patient in obtaining appropriate medical care. Furthermore, the family, guardian, and/or patient hereby gives permission to any agent that will assume all liability for any medical expenses, hospital care, or other expenditures without liability to Open Mind Psychiatry.

Financial Responsibility

Patient and/or financially responsible party have been informed she/he is financially responsible for services received at Open Mind Psychiatry, unless payment is otherwise assured. The patient and/or financially responsible party have been further informed of pricing prior to or on first scheduled appointment. If, for any reason your insurance fails to pay any portion of the amount we billed, you will be responsible for the balance and will be billed accordingly. All copays and deductibles are due at the time of service. Copays and deductibles are based on a verification of your benefits with your insurance provider. Insurance verification is a general quote of your benefits based on the levels of care Open Mind Psychiatry provided. Charges can be subject to change after final determination of claims by your insurance provider. Charges may be less or more than what is billed at the time of the appointment. If patient and/or financially responsible party elect to be charged under our SELF-PAY rates, Open Mind Psychiatry charges $250 for the initial doctor’s appointments. Continuation of therapy, including medication management follow-ups will be charged at $150.00 each appointment. Appointments scheduled with a therapist will be billed at $100 for each appointment under the SELF-PAY rates. It is agreed the patient will provide Open Mind Psychiatry with a permanent contact address and telephone number.

If patient and/or financially responsible party elects to pay the appointment by check, allow up to 3-5 business days for your check to process. Returned checks are assessed a $30.00 fee and patient and/or financially responsible third party will no longer be allowed to pay by check for any future appointments. Returned check fees must be paid prior to scheduling any new appointments.

If patient/and or financially responsible receives a bill by mail, you agree to pay your bill within 10 days of receipt. If payment is not received within 90 days, your account will be turned over to collections. We have the option to pursue all lawful collection procedures available and the patient/parent/financially responsible party will be responsible for all the reasonable costs of collection, including attorney’s fees incurred, if any. The minimum collection fee will be 50% of the total account balance. Unwillingness to pay may result in termination of services.

Cancellations and No-Show Policy

We see all patients on an appointment basis. If you are unable to keep your scheduled appointment, please cancel as soon as possible so your allotted time maybe given to another patient. If the appointment is cancelled within 24 hours of the scheduled time, a $50 fee will be assessed to your account, unless sufficient reason is given for the cancellation to waive the fee. Patient may need to provide documentation to have fee waived. If you fail to attend your appointment without any prior notice or communication, a $50 no-show fee will be assessed to your account. Fees must be paid before the patient can schedule any new appointments.

Re-Occurring Appointments Policy

Patients may request to be setup on a re-occurring schedule with the provider(s) they see. In order for re- occurring schedules to be setup, the patient and/or financially responsible party must put a credit card on file, if they are subject to a copay or deductible. Patient and/or financially responsible party may change credit card information at any time after setting up the re-occurring schedule. If payment fails to go through, we will contact patient and/or financially responsible party prior to appointment to reconcile payment. If patient and/or financially responsible party fails to answer communications or fails to communicate
to Open Mind Psychiatry a change in payment information, the appointment will be cancelled as well as the re-occurring appointment schedule.

Records

Requests for records are received from various sources. Attention to these requests will only occur when we have received a signed authorization of release form from the patient (if patient is under 18, parent signature is also needed). Records are copied at $30 plus postage and billed directly to you. Please allow two weeks for this request to be processed.

Letters

Letters and forms are often requested by patients (or their parents) to be sent to school, employers, etc. You will be charged a fee for these services. A minimum of $50.00 will be billed directly to the patient and not the insurance. This does not include an excuse of absence letter needed for school.

Telephone Calls

Your calls are welcome, and we will return them promptly during business hours. We do not have after hour answering services. You must call the office and leave a voicemail message. If you need to make an appointment, please call during business hours. If you have an emergency, please call 911 or go to the nearest emergency room.

Prescriptions

To prevent error and to maintain insurance and healthcare standards most prescription cannot be called into the pharmacy. There is a charge of $10.00 for prescription that are misplaced, lost or not filled in the 21-day time frame for controlled substances. You must return the expired prescription and pay the fee.

Notice regarding medication refills

We require 3 BUSINESS DAYS NOTICE for prescription refills to be sent to pharmacy or to be picked up at the office.

Termination

Open Mind Psychiatry termination policy is after the third consecutive no-show appointment without any communication can lead to termination, non-negotiable. If there is no follow up appointments completed within four months , the patient will be regarded as termination of treatment on the part of the patient and in turn discharged from Open Mind Psychiatry, unless we have decided as a team otherwise. If you fail to comply with treatment recommendations, termination may occur and this is non- negotiable.

Confidentiality

I have further been assured that my information, knowledge, or records associated with said patient are subject to release only by my informed and written consent of by a court order, expect in instances of medical emergency or suspected child or elder abuse or neglect. Your confidentiality and privacy are protected by the following Federal guidelines: Code of Federal HIPAA

1. I understand that I am voluntarily engaging in a telemedicine consultation with Open Mind Psychiatry. 

2. I understand that the video conferencing technology and/or phone consultations will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.

3. I understand that a telehealth consultation has potential benefits including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home.

4. I understand there are potential risks to this technology, including interruptions, unauthorized access, and technical difficulties. I understand that my health care provider or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.

5. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. I understand that if there is another individual present during the telehealth consultation that I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.

6. I understand that the alternative to a telemedicine consultation is to forgo evaluation and treatment with Dr. Celina Egemasi, DNP, APRN, NP-C, PMHNP-BC at Open Mind Psychiatry and to seek out an in-person evaluation elsewhere. Thus, I am freely choosing to participate in a telemedicine consultation.

7. I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through Open Mind Psychiatry will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care provider or not done at all.

8. Telemedicine services offered through Open Mind Psychiatry are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.

9. To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.