About Me

You consent for yourself/your child to receive a comprehensive diagnostic assessment.
At the end of the evaluation, we will mutually decide if we will continue treatment
together.
If there is a potential of any physical danger to you, your child, or others, you will call
911 immediately or go to the closest emergency room. To reach me outside of standard
business hours, follow the instructions on my voicemail.

Note I do not have admitting privileges, nor am I affiliated with or on staff at any hospital.
Should I deem more intensive services are needed than I can provide, I will do my best
to ensure safety and obtain the appropriate level of care, but I cannot provide that care
directly and cannot guarantee the receipt or quality of care that others provide.

Any controlled substance would be prescribed only if clinically indicated and I would
appreciate it for not being pressured to prescribe controlled substances if they are not
indicated or could potentially cause harm.
* If you/your child are prescribed controlled substances then the clinic has the right to
ask for urine drug screen from time to time and that is not because we do not trust our
patients but are considered good practicing guidelines in order to keep the patient, the
provider and community safe.
Risks and benefits of psychotherapy: Psychotherapy has both benefits and risks.
Possible risks include the experience of uncomfortable feelings (such as sadness, guilt,
anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant
events. Potential benefits include a reduction in feelings of distress, better relationships,
better problem-solving and coping skills, and resolution of specific problems. Given the
nature of psychotherapy, it remains an inexact science and no guarantees can be made
regarding the outcome.

There is no guarantee of confidentiality under the following conditions:
* If I suspect you/your child are/is in imminent danger of harm to self or others, or a child
or elderly person is being abused or neglected (as I am a mandated reporter)
* If a court orders a release of information
* If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
* If your insurance company requests to review your/your child’s case
* If you pay by credit card, my name will appear on your credit card statement
* If you do not pay your bill, your balance due statement (including diagnostic and
procedural codes) may be sent to a collection’s agency or other responsible party
* Between me and my administrative staff, or colleagues with whom I consult
professionally

You confirm you have reviewed my HIPAA privacy practices here:
https://www.hhs.gov/hipaa/for-individuals/guidance-materials-for-consumers/index.html

Not taking insurance and charging a fee for service with the following fee structure.
You agree to pay professional fees as follows:
1) Full psychiatric Assessment is one hour: 350 $.
2)Follow up:
A) 30 minutes follow up: which is the usual time allocated for most of the follow
up appointments: 220 $.
B) 40 minutes follow up: if required given the complexity of the clinical picture :
250 $.

Patients from states other than Colorado:

1) Initial Evaluation: $400

2) Follow Up: $275

Payments can be made online via patient portal using a credit card or a debit card.
There is a 2.99% processing fee charged per transaction by the vendor. Bank cheques
are also accepted. As a policy it is mandatory to have a credit card/debit card
information stored in the patient’s chart and that patients do give us the
permission to charge for the balance.

You may also make the payment online but payment should be made within 24 hours
after the appointment, otherwise a late charge fee of 5% will be added for each day that
payment is delinquent for.

Anthem (Blue Cross Blue Shield)

Cigna

Aetna

We will provide you with a bill documenting your appointment, amount of time spent and
the CPT code that you can send to your insurance company for refund of the amount of
money that would be authorized depending upon their policies.

The payment will be made from the credit card/debit card provided by the
patient/guardian after the session is completed and you authorize the clinic/provider to
charge your card.

If you fail to notify the clinic about cancelling or rescheduling the appointment within 24
hours prior to the scheduled appointment, then full charge for that appointment will be
made from the account.
You agree to pay for any time spent in your or your child’s care outside of session time
on a prorated basis (unless otherwise detailed below). Unfortunately, insurance
companies typically do not reimburse for this. Some examples include, but are not
limited to:
* No shows/rescheduling with less than 24 hours business hours’ notice: full session
charge. For example, if you or your child’s appointment is on Monday at 4pm, you will
communicate your cancellation no later than the previous Sunday at 4pm; if an
appointment is on Tuesday at 10am, you will communicate no later than Tuesday at
10am.
* Phone calls, messages in the patient portal, voicemails, letters, video sessions and
texts between me and: you, your child, or other physicians, therapists, teachers, family
members, insurance companies, etc.
* Prescription refills outside of session time
* Time spent obtaining prior authorizations
* Coordination of care for emergencies, hospitalization, intensive outpatient, residential
treatment, rehabilitation, etc.
* All forms (insurance, worker’s compensation, school, employer; doctor’s notes, letters,
or reports) and chart reviews not filled out in session
* Testimony in court, at depositions, administrative hearings, board reviews, and all time
required for preparation and travel, whether requested by you or ordered by a court,
board, government agency or other legal authority
* There is a 5% late fee per day if appointment fee is not paid within 24hours after the
appointment, and they may be submitted to collections after 30 days, along with any
associated collections fees
* There is a $ 50 fee for returned checks (which will also result in your credit card
automatically being run for the balance due) or credit/debit card charge refused by the
financial institution and for credit card chargebacks that are unsubstantiated
You are financially responsible for all charges, whether or not:
* Insurance pays for any services

* We decide to proceed with treatment
* Treatment is successful, for which there cannot be any guarantee
You affirm you are an authorized user of the credit card whose number and expiration
date supplied, and you do authorize its use for all fees incurred.
By typing your signature below, you confirm you have read the above and agree to
these terms and conditions.
Smoking or drinking within the premises is not allowed.
As we will try our level best to be professional courteous while taking care of you, we
would also expect our patients to do the same and be respectful of other patients who
are visiting the clinic.
Recommendations and suggestions on how we can further improve further are always
welcome.