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TREATMENT CONTRACT AND OFFICE POLICIES

PATIENT PAYMENT OBLIGATIONS. All outpatient visits must be paid for at the time of visit. You will be provided with a receipt for you to submit to your insurance company. Capital Mental Health, LLC cannot accept responsibility for negotiating claims with insurance companies or other persons. You are responsible for payment of your medical care regardless of the status of your claim. Any other financial arrangement must be made with Capital Mental Health prior to service.

MISSED OR CANCELED APPOINTMENTS WITH LESS THAN 24 BUSINESS HOURS NOTICE. Should you need to cancel a session, please do so at least 24 hours in advance. Otherwise, the time you have booked will not be scheduled for anyone else, and you will automatically be charged at your regular rate for the cancelled session.

RETURNED CHECKS. You will automatically be charged for the amount of your returned check plus a $30 fee.

OUTSTANDING BILLS. Outstanding bills will be re-billed monthly. If payment is not received after two successive billings, your account may be sent to a collection service.

ROUTINE CLINICAL QUESTIONS BETWEEN VISITS. For routine clinical concerns and questions, please leave a message on Capital Mental Health’s voice mail at (240) 743-4535. They will call back as soon as possible, usually by the next business day. Note that Capital Mental Health’s office does not check messages on weekends, federal holidays, or after 5 pm on weekdays (4 pm on Fridays).

URGENT/EMERGENT SITUATIONS. If your situation is emergent (e.g., life threatening), call 911 or go to your nearest emergency room. If your situation can wait for Capital Mental Health or the covering clinician to return your call, then call Capital Mental Health’s office phone number (240) 743-4535 and listen to the outgoing message for the clinician’s contact information or instructions on how to contact the covering clinician.

PHARMACY REQUESTS. Capital Mental Health’s office requires at least 48 business hours in advance to respond to prescription refill requests. Urgent prescription requests requiring a response in less than 48 business hours may be charged the applicable fee for urgent prescription requests. Prescription refill requests can only be provided to current patients of the practice.

VACATIONS. Capital Mental Health’s outgoing message on (240) 743-4535 will notify callers that a clinician is out of town and will leave instructions on how to contact the covering clinician.

AGREEMENT

OFFICE POLICIES

  • I have read and understood and I agree with the foregoing, and consent to this evaluation and/or treatment. I hereby acknowledge full responsibility for the payment of services rendered by the practice or Capital Mental Health, LLC. I agree in the event of non-payment to bear all the costs of collection, court costs and legal fees as are required. A facsimile or photocopy of this signature is as valid as the original.
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