1. Electronic records:
• Records sent electronically such as fax, email or portal uploads – record handling fee will be $20.
• When the file size of records is too big for emails, fax etc. we may not be able to send them via these methods. We may either limit the size for most recent records or may provide ability to download from our portal.

2. Paper copy requests:

To cover the costs incurred in searching, handling and copying medical records a fee for each request shall be:

$0.75 per page for the first 25 pages

$0.50 per page for pages 26 through 100

$0.25 for each page in excess of 100 pages

A minimum fee of up to $10.00, inclusive of copying costs, for mailing medical records for the patient or the patient’s designated representative

MAILING charges are additional determined based on actual cost of mailing, either USPS, or via courier services as requested by the recipient.

• Telephone charges are based upon the provider’s standard fee per 45 minutes and prorated per minute.
• There is no charge for calls under 5 minutes concerning side effects of medications that you have been prescribed by a provider. However, if the medication call involves phoning in or otherwise reissuing a prescription, you will be charged.
• Prior Authorization: If the provider have to obtain prior authorization for your medication in order for your insurance to cover it, we reserve the right to assess a fee of $15 towards administrative cost.
• There may be a $25.00 charge for calling in a refill or writing a prescription to be picked up without an accompanying patient visit. The on-call provider will only provide enough medication to last until your regular clinical visit.
  

Appointments:

While we cannot guarantee an appointment with a clinician at your most convenient time; but we do our best to accommodate you. Your care is very important for us.

If you are unable to keep an appointment, please notify our office immediately. This time is reserved exclusively for you.

If an appointment is cancelled or missed without 24 business hours notice, you may be billed for the session.

Some appointments are scheduled over the phone, and not in person. Our Assistant may call with your appointment date and time as a reminder, and may leave a message on your answering machine, or with a responsible party in your household, unless you specifically request us not to do so.

With or without an answering machine or other party telephone reminder,  you are still responsible for cancelling with 24 hours notice, or you may be billed for the session as above.

Payment:

As a courtesy to you, Alpha Psychiatric Associates PLLC will normally accept assignment of any insurance benefits you may have and file health care claims directly to your insurance company. However, payment of all applicable copays and deductibles (or any other amount not covered by your primary insurer) is required at the time services are rendered. Payment may be made by cash, check, credit or debit card. Every client is asked to sign a “Financial Acceptance” agreement that is appended to this document. If you are unable to pay your obligation at the time of service, we may ask you to authorize Alpha Psychiatric Associates to charge your credit card for any balance due more than 60 days old. Please note that we will not charge your credit card if there is no balance due more than 60 days old.

There will be a $25.00 service charge for returned checks.

PLEASE NOTE: We accept ONLY cash or credit card during your first appointment, no checks please!

Notwithstanding the former, Alpha Psychiatric Associates reserves the right to demand full payment for services rendered at the time of service. If you are covered by more than one insurance company and we receive prompt payment from your primary insurer, Alpha Psychiatric Associates will normally file claims to your secondary insurer as a courtesy to you. However, pending payment by your primary insurer, you may be asked to make payment at the time services are rendered of any amounts covered by your secondary insurer.

Alpha Psychiatric Associates, PLLC will not be able to file claims to your insurance company unless you provide us with accurate and complete information about your insurance plan. Accordingly, we ask you to review your policy carefully and to be aware of any limitations on your benefits. You must also promptly inform us of any changes in your insurance coverage or we will not be able to file your claims. Similarly, many insurance companies are now managing their mental health benefits. This means you must consult your insurance booklet to see if your insurance must approve sessions before they occur. If this approval is not obtained, your insurance will not cover the sessions. If you are not sure, please ask Alpha Psychiatric Associates, PLLC to help you with these prior authorizations.

• Any confidential information you disclose to us during treatment, or any other confidential information we obtain while attending to you professionally, shall be held in confidence unless you permit us to disclose such information or where we are required to disclose such information by law.
• By signing this contract, you are agreeing to the disclosure of confidential information where such disclosure is necessary to obtain certification, authorization, or payment for your treatment, or where we are required to disclose information by the terms of our contract with your insurer or managed care company. For example, in order for your insurance company to cover your treatment, we may be required to periodically communicate details of your condition and treatment with them or with your managed care case manager. You are also expressly authorizing your provider to pursue appeals and grievances with insurers or managed care companies when those appeals are necessary to obtain payment for one of your insurance claims or when your provider believes an appeal of denial of care by your insurer is appropriate or necessary .
  
• By signing this contract, you are agreeing to the disclosure of confidential information to other physicians or therapists familiar with your case, where your provider decides it is clinically necessary or appropriate to do so. For example, if a physician or psychotherapist referred you to us for evaluation and treatment, our providers may communicate with that professional about your condition and treatment. Please tell us in advance if you want certain information withheld. Similarly, if we refer you to another physician or therapist within Alpha Psychiatric Associates for treatment, that provider will have access to your records and may communicate with your prior provider(s).

Forensic Matters:

Alpha Psychiatric Associates, PLLC may be required by law to disclose confidential information in certain cases. The following are examples:

Court Appearances:

In certain cases, an Alpha Psychiatric Associates, PLLC clinician may be willing to act as an Expert Witness in a court action involving a client. If you wish to engage the services of a clinician as an Expert Witness, you must read and sign an Alpha Psychiatric Associates, PLLC Expert Witness Agreement that binds you to payment for the clinician’s time in preparing for court, appearing in court, preparing reports, communicating with attorneys, etc. Please discuss the possibility of court appearances with your doctor or therapist as far in advance as possible.

In the event that an Alpha Psychiatric Associates, PLLC clinician is subpoenaed to appear in a court action involving the care that was delivered to you or to a family member, you will be charged that clinician’s standard fee for court appearances, etc. even in the absence of a signed Expert Witness agreement. Even if the subpoena is not issued by your attorney, but rather by an adverse party, you will be charged for and expected to pay the clinician’s fees for these services.

On Call:

Several providers share a rotating on-call schedule, after hours and weekends. You may leave a phone message which will be picked up on Monday.

If you think you or your family member may require hospitalization, please call the Respond Service at Holly Hill / Charter Hospital at 1-800-447-1800 for a free consultation 24 hours a day.Click here for the list of crisis centers by county.

For emergencies call 911.