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New Patient Appointment Form

Please complete the following form. Please note at this time we are NOT accepting new patients for Therapy or Counseling. Thank You

Email address is required.
PLEASE NOTE: If your insurance is not listed then we are NOT accepting new patients with that insurance at this time. Entering the wrong information will result in your appointment being self pay.
At this time we are NOT accepting new patients for Therapy or Counseling.
I understand I will be charged a missed appointment fee if I do not give 24 hour BUSINESS notice to cancel. After 3 Missed appointments, I will be eligible for termination. Medication Management missed appointment fee is $50 - Therapy missed appointment fee is $75
(1)OFFICE VISITS/ BALANCES - All fees are due at the time service is rendered. We accept cash, checks, MasterCard and Visa. Payment plans are available through the billing department for balances. (2) RETURN CHECK FEE - There is a $35 fee for all return checks. In the event that this happens, you will be required to pay cash for future visits. (3) NEW INSURANCE - 24 hours (BUSINESS HOURS) advance notice is required. Delays in getting the new insurance or correct information will delay payment and may result in a denial and possible non-payment. Failure to give 24 hour notice will result in paying cash for that days visit.(4) CANCELLATIONS - Cancellations must be made 24 hours (BUSINESS HOURS) before your appointment. The 24 hours does NOT include non-business days/ hours. Failure to give 24 hour notice on a canceled appointment will incur a fee based on appointment type ranging from $50 - $75. (5) REFILLS - All medicines will be refilled ONLY at the time of appointment. Medications are prescribed to only last until your next appointment. You will need to schedule the next available appointment to get a medication refill. (6) MEDICATION CHANGES - All medication changes will require an appointment. You will need to schedule the next available appointment. (7) MEDICATION CHECKS - Medication checks are scheduled for 10-15 minutes. In order to receive your entire session, please be prompt for your appointment. For sessions that extend past 15 minutes, an additional change will be applied. If you are late to your scheduled appointment, we will work you in if time becomes available. (8) ADDITIONAL CHARGES - We charge for completion of paperwork, letters, forms, etc. Fees will be determined based on the paperwork. There is also a fee for medical records. This fee is standard based on Texas State Regulations. All forms will be completed within 7- 14 business days after completion of payment and medical release (9) APPOINTMENTS - Due to the high volume of appointment being made, please schedule your follow up before leaving our office. This is the only guarantee you will get in before you run out of your medicines. Waiting to schedule your appointment may result in missing your return to clinic date and/or medications running out. (10) PAGING SYSTEM - There is a 24 hour paging system for emergency situations. There is a fee charged for all non-emergency after hours calls. (11) EMERGENCY SERVICES - I agree to contact my provider or 911 in the event that I feel suicidal or violent in order to follow steps to protect the safety of others and myself. (12) INSURANCE SERVICES - The Office participates with many health plans. AS A COURTESY TO OUR PATIENTS, we will file claims with these companies; however, it is ultimately your responsibility for the full and timely payment of your account. Please be prepared to submit your current insurance card at each visit. A scanned copy of this card may be kept as part of your permanent record. Please also provide the office with up to date contact information including your home address, telephone number, and emergency contact information. The office will attempt to verify coverage and benefits prior to your visit with the physician. If we are unable obtain a verification of coverage you will be asked to pay in full or reschedule your visit at a time the verification can be obtained. This verification will be used to estimate your financial responsibility; however, this verification is not a guarantee by your health plan of coverage or payment. Payment of your estimated patient liability is expected at the time services are rendered. This payment will include know deductibles, co pays, and co insurance due for this visit and/ or physician hospital charges. While we may estimate your financial responsibility, it is the insurance company that makes the final determination regarding your eligibility and benefits. In the event that your insurance company fails to pay, all or in part, you will be expected to pay the balance in full. Please be aware that certain diagnoses may not be covered or may be considered; not medically necessary by your health plan. You are responsible for payment of these services. Please also be aware that many health plans limit annual coverage. In the event your care exceeds a plan limitation, you will be responsible for the balance. It is your responsibility to know the benefits and limitations of your current health care coverage. Kingwood Psychiatry will provide care based on the patient's needs, not a patient's insurance coverage. Your Physician is NOT responsible for knowing your plans specific benefit and coverage limitations. (13) PAST DUE BALANCES - If your account becomes past due we will take necessary steps to collect this debt. Referral to a collection agency may adversely impact your credit record. Accounts turned over to collection agencies may also result in you being dismissed from Kingwood Psychiatry. A representative in our business office is available to answer any questions you may have regarding your account. Payment plans are available. (14) CONSENT FOR TREATMENT - I give full consent to receive services until I notify the attending Provider of any changes or until he determines that treatment is no longer necessary. I certify that I have right to seek and authorize treatment for myself. (15) ABUSIVE BEHAVIOR - Kingwood Psychiatry has the duty to provide a safe and secure environment for the patients and staff. Violent or abusive behavior will not be tolerated and decisive action will be taken to protect the staff and patients. Those who display this behavior will be immediately asked to leave and be terminated from the practice. --- I acknowledge receipt of Kingwood Psychiatrys Polices and I certify that I understand these policies. Any questions have already been explained. I am aware that these policies may change at any time.
- I hereby authorize Kingwood Psychiatry to release information acquired in the course of my treatment to my insurance company, employer based health plan, or third- party payer as required of claims filed, quality assurance, health plan administration, complaints/ grievances. I authorize direct payment to be made to Kingwood Psychiatry. I understand that I am responsible for all charges if any services are not covered by insurance or Kingwood Psychiatry is unable to verify eligibility. I grant Kingwood Psychiatry the rights to coordinate benefits with other insurance coverage and to collect against another party for reimbursement of expenses, if my visit is reimbursable by that party. INSURANCE SERVICES - The Office participates with many health plans. AS A COURTESY TO OUR PATIENTS, we will file claims with these companies; however, it is ultimately your responsibility for the full and timely payment of your account. Please be prepared to submit your current insurance card at each visit. A scanned copy of this card may be kept as part of your permanent record. Please also provide the office with up to date contact information including your home address, telephone number, and emergency contact information.The office will attempt to verify coverage and benefits prior to your visit with the physician. If we are unable obtain a verification of coverage you will be asked to pay in full or reschedule your visit at a time the verification can be obtained. This verification will be used to estimate your financial responsibility; however, this verification is not a guarantee by your health plan of coverage or payment. Payment of your estimated patient liability is expected at the time services are rendered. This payment will include know deductibles, co pays, and co insurance due for this visit and/ or physician hospital charges. While we may estimate your financial responsibility, it is the insurance company that makes the final determination regarding your eligibility and benefits. In the event that your insurance company fails to pay, all or in part, you will be expected to pay the balance in full.Please be aware that certain diagnoses may not be covered or may be considered; not medically necessary by your health plan. You are responsible for payment of these services. Please also be aware that many health plans limit annual coverage. In the event your care exceeds a plan limitation, you will be responsible for the balance. It is your responsibility to know the benefits and limitations of you current health care coverage. Kingwood Psychiatry will provide care based on the patients needs, not a patients insurance coverage. Your Physician is NOT responsible for knowing your plans specific benefit and coverage limitations. PAST DUE BALANCES - If your account becomes past due we will take necessary steps to collect this debt. Referral to a collection agency may adversely impact your credit record. Accounts turned over to collection agencies may also result in you being dismissed from Kingwood Psychiatry. A representative in our business office is available to answer any questions you may have regarding your account. Payment plans are available. CONSENT FOR TREATMENT - I give full consent to receive services until I notify the attending Provider of any changes or until he determines that treatment is no longer necessary. I certify that I have right to seek and authorize treatment for myself. CONSENT FOR EMAILS - I give full consent to receive emails from Kingwood Psychiatry.CONSENT FOR TEXT MESSAGES - I give full consent to receive text messages from Kingwood Psychiatry.
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