New Patient Registration Form – Test 3.9

Practice Policy

In the event of an emergency situation, go to your nearest emergency room or call 911

Thank you for choosing Mid Cities Psychiatry for your psychiatric care! Our team of providers specializes in psychiatry, offering high-quality and specialized behavioral health services with an emphasis on comprehensive psychiatric treatment. Our Medical Director, Dr. Kazi, is exceptional. She oversees our team, provides clinical guidance, is beloved by her patients, and ensures the delivery of exceptional mental health care. Our administrative staff plays a vital role in ensuring the operations run smoothly, handling patient inquiries about billing, appointments, insurance, and more. To help us serve you better, we kindly request that you review and complete the following forms in its entirety at least one business day before your appointment.

Here are the expectations we set for patients at our clinic to ensure a safe environment, maintain a manageable workload for our team, and provide clear timelines for patient requests:

1. Medications and Refill Requests

a. To request a refill your pharmacy must fax a refill request form to us at 855-295-2686 at least 4-5 business days before your medications end. Please allow at least 4 business days for refill requests to be completed.

i. Business days at Mid Cities Psychiatry do not include weekends or holidays; therefore, refill requests will not be processed on these days. They will be processed on the next business day.

b. Prescriptions for Schedule II controlled substances are strictly regulated and monitored by the Texas Prescription Program. A fee of $25.00 will be charged for requests made between office visits.

c. If you lose your prescription or need a refill, it will be provided only after the provider's approval at your next scheduled appointment, and a $25.00 fee will apply. If you do not have an upcoming appointment, we will schedule one for you as soon as possible.

d. Some medications require prior authorization from your pharmacy, which may take 4-5 business days depending on your insurance coverage.

e. Patients who have not been seen by a provider in the last 60 days or more may be required to schedule a follow-up appointment before a refill request can be considered. This decision is the provider’s discretion.

f. Patients may be considered inactive if they have not been seen by a provider or have not been in contact with the provider for four months or more.

2. Communication

a. Our administrative staff manages all appointment requests and correspondence. We strive to return your call within one business day.

b. As a general guideline, please make effective use of your time with the provider.

i. For any questions or concerns regarding billing charges or your account balance, please request the front desk to speak with our billing staff or Practice Manager.

3. Termination of Physician-Patient Relationship

a. It is the policy of Mid Cities Psychiatry to foster a cooperative and trusting physician-patient relationship. However, if this relationship fails to form or ceases to be mutually productive, termination may be considered under certain circumstances. These include, but are not limited to:

i. Treatment/Follow-up Nonadherence: Failing to follow the prescribed treatment plan, abusing medications, tampering with prescriptions or documents, or repeatedly canceling or missing follow-up visits.

ii. Verbal Abuse: Rude behavior or improper language by the patient, their family members, or friends towards office personnel, as well as exhibiting violent behavior, making threats of physical harm, or actions that threaten the safety and well-being of office personnel.

iii. Distrust: Engaging in deceptive behaviors or lying.

iv. Nonpayment: Failing to pay bills in accordance with our payment policy, accumulating unpaid bills without working with the office to establish a payment plan.

4. Guidelines for Continued Care

a. Your appointment is reserved exclusively for you, and it is your responsibility to keep it. As a courtesy, Mid Cities Psychiatry will send you three appointment reminders. We value both your time and our providers' time, which is why we do not overbook or double-book appointments.

b. Patients are entitled under federal law to access their medical records. We adhere to all applicable rules, guidelines, and exceptions to ensure compliance with patients' rights. Please allow at least four business days to process your request.

c. If you require a phone call or tele visit session with a provider, it will be billed at the standard office rate.

d. For completion of FMLA/STD/LTD or other forms, an appointment with a provider is necessary.

e. If medication has been continuously prescribed by the practitioner and you become an inactive patient, a maximum of one month of medication may be prescribed while you find an alternative healthcare provider.

f. Inactive status may be instituted after three missed appointments within the last 90 days.

g. If you (or your legal counsel) request, summon, or subpoena the participation or testimony of any Mid Cities Psychiatry team members for any legal proceedings, including trials or depositions, you must provide payment at the team member’s hourly rate (three-hour minimum) or as restricted by law, 48 hours in advance of the participation. Mid Cities Psychiatry team members must be notified at least five business days prior to the event. Failure to provide timely notice or payment may result in Mid Cities Psychiatry seeking to quash the subpoena or refusing participation, and we may seek reimbursement from you for any legal fees incurred in obtaining court protection against such participation.

Payment / Balance / Cancellation / Rescheduling / No-Show Policy

Here are the expectations we set for patients at our clinic to ensure that both patient and provider time is respected and helps maintain the quality and timeliness of the healthcare services we provide:

1. Payment Obligations:

a. Mid Cities Psychiatry is not obligated to provide services if you cannot pay copays, co-insurance, deductibles, or clear outstanding balances unless payment arrangements are made.

b. In the event of financial difficulties, please contact us as soon as possible to discuss potential arrangements.

c. If a payment is not received by the due date under a payment plan, a late fee of $25.00 will be charged. Future appointments may be canceled if a payment is missed.

d. Upon a missed payment:

i. Your full balance must be cleared before any future appointments can be scheduled.

ii. Payment must be received within 21 days of the missed payment date, or your account may be referred to collections, and the physician-patient relationship may be terminated.

2. Cancellation, Rescheduling, and No-Show Fees:

a. A fee will be automatically charged to your credit card on file for any appointment that is canceled or rescheduled within 24 business hours, or if you do not show up, as per the RCN Fee schedule.

b. If you arrive more than 15 minutes late, you will not be seen, your appointment will be rescheduled, and your card will be charged according to the RCN fee schedule.

c. These fees are nonrefundable. However, in cases of emergency, proof may allow for the charges to be discounted or waived at the next appointment.

d. Missed appointments will be recorded in your file. Accumulating three no-shows within 90 days may lead to the termination of our physician-patient relationship, as outlined in our policies.

3. Cancellation / Rescheduling / No-Shows (RCN) Policy:

a. Automatic charges apply per the RCN Fee schedule for cancellations or rescheduling with less than 24 business hours' notice or for no-shows. Arriving over 15 minutes late will also incur automatic charges.

b. Cancellation / Rescheduling / No-Shows Limit per 90 days is maximum one (1).

4. RCN Fee Schedule:

a. 40 minutes meds management appointment no-show fees would be $150.00

b. Psychologists' appointment no-show fees would be $150.00 per hour

c. Therapist's appointment no-show fees would be $150.00

d. 20 minutes meds management appointment no-show fees would be $75.00

Credit-Card Information

Patient Financial Policy

To minimize confusion and misunderstandings between our patients and practice, we have adopted the following financial policies. If you have any questions about these policies, please feel free to discuss them with us. We are committed to providing the best possible care and service, and consider your understanding of your financial responsibilities to be an essential part of your care and treatment.

Unless other arrangements have been made in advance by either you or your health insurance carrier, full payment is due at the time of service.  For your convenience, we accept payment by check (payable to Mid Cities Psychiatry), cash, debit card, Visa or Mastercard.

1. Patient Insurance

a. We have established agreements with many insurers and health plans to accept an assignment of benefits. This means we will bill those plans with which we have an agreement, and you will only be required to pay the authorized co-payment at the time of service. It is our policy to collect this copayment when you arrive for your appointment.

b. Your assistance may be needed to secure timely payment of your claims. If your health plan mandates that you obtain prior authorization in the form of a referral from your primary care physician, or precertification before procedures or treatment plans can be initiated, please inform our staff in advance so that we can ensure these requirements are met.

c. If you are insured by a plan with which we do not have an agreement, we will prepare and send claims on your behalf. However, you should be aware that your share of the medical fees may be higher when using non-contracted physicians compared to contracted ones.

d. Please be aware that not all services may be covered under your insurance plan, and certain services might be excluded. If your insurance determines a service is “not covered,” you will be responsible for the full cost. Any amount designated as your responsibility must be paid upon receiving a statement from our office..

e. We will bill your health plan for all services provided at Mid Cities Psychiatry. Any balance due is your responsibility and should be paid upon receipt of a statement from our office or from your insurance.

2. Insurance Claim Processing and Payment Responsibilities

a. Please do not presume that your insurance carrier is actively processing your claim. If you have not received notification of payment within 30 to 45 days following your treatment, it is important to contact your insurance provider directly. Should there be a delay in payment, we kindly request that you engage with your insurance or health benefits office to resolve any pending issues. In the event that your insurance company denies payment, citing that the services rendered by Mid Cities Psychiatry are not medically necessary, this consent grants Mid Cities Psychiatry the authority to seek payment directly from you for those services. Ultimately, you will be responsible for any services not reimbursed by your insurance.

3. Patients who are Minors

a. For all services provided to minor patients, we will seek payment from the adult accompanying the patient, or from the parent or guardian who has custody.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Uses and Disclosures

Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, the physician in this practice is a specialist. When we provide treatment, we may request that your primary care physician or other specialists share your medical information with us. Also, we may provide your primary care physician and other specialists with information about your condition so that he or she can appropriately treat you for other medical conditions, if any. In addition, results of laboratory tests and procedure will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.

Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and medical condition being treated.

Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of our practice. For example, your health plan may request and receive information on dates of service, the services provided, and medical condition being treated.

Law enforcement. Your health information may be disclosed to law enforcement agencies to support government audits and inspections, to facilitate law enforcement investigation, and to comply with government mandated reporting.

Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing the use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your authorization.
Additional Uses of Information

Appointment Reminders. Your health information will be used by our staff to send you appointment reminders via the telephone, electronic mail / texts and/or US mail.

Information about treatments. Your health information may be used to send you information that you may find interesting on the treatment and management of your medical condition. We may also send you information describing other health-related products and services that we believe may interest you.
Individual Rights

You have certain rights under the federal privacy standards. These include:
The right to request restrictions on the use and disclosure of your protected health information.
The right to receive confidential communications concerning your medical condition and treatment.
The right to inspect and copy your protected health information.
The right to amend or submit corrections to your protected health information.
The right to receive an accounting of how and to whom your protected health information has been disclosed.
The right to receive a printed copy of this notice.

Practice Duties
Law requires us law to maintain privacy of your protected health information and to provide you with this notice of privacy practices. We also are required to abide by the privacy policies and practices that are outlined in this notice.

Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice on any office visit. The revised policies and practices will be applied to all protected health information we maintain.

Requests to inspect Protected Health Information
You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the receptionist or the Privacy officer. Your request will be reviewed and will generally be approved unless there are legal or medical reasons to deny the request. You will be charged a fee as limited by The Texas State Board of Medical Examiners for the copy of your records.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can contact us to let us know. If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern. You will not be penalized or otherwise retaliated against for filing a complaint. You may also send a letter outlining your concerns to the U.S. Department of Health and Human Services.

Patient Communication Consent Form

From time to time, we may need to communicate with you and to preserve your privacy, we would like for you to indicate your preferred method for us to communicate with you. Examples of such information to be communicated include appointment dates, appointment reminders, appointment follow-up, test results, billing questions, and other information clinical in nature.

If no one is available to answer your phone, we request your permission to leave certain types of information on your answering machine, voicemail, or email. Please fill out the following and then indicate your preference by clicking the checkbox below below;

I give permission to Mid Cities Psychiatry personnel to leave the following forms of information pertaining to me on answering machine, voicemail or e-mails listed below.

This consent may be revoked at any time through written notification, except to the extent that action has already been taken based on this consent.

Share Your Experience with Us

Our number one priority is your satisfaction. Reviews are an important part of our practice, and we value your feedback. After your appointment, we will send you a text message inviting you to share your experience with us. Please note that only your first name and last initial will be displayed on your review. Your email will not appear on the review, and we will never share it with third parties.

1. RISK OF USING EMAIL

Transmitting patient information via email entails several risks that patients should consider before utilizing this form of communication.
These risks include, but are not limited to:

a) Circulation and Storage: Email can be circulated, forwarded, stored electronically and on paper, and inadvertently broadcast to unintended recipients.

b) Misaddressing**: It is easy to misaddress an email, which could result in information being sent to the wrong recipient.

c) Backup Copies: Backup copies of emails may exist even after the sender, or the recipient has deleted their respective copies.

d) Inspection by Third Parties: Employers and online services have the right to inspect emails transmitted through their systems.

e) Security Breaches: Email can be intercepted, altered, forwarded, or used without authorization or detection.

f) Viruses: Email can serve as a medium for introducing viruses into computer systems.

g) Legal Evidence: Emails can be used as evidence in court proceedings.

h) Lack of Security: Emails may not be secure, which could potentially lead to a breach of confidentiality by third parties.

2. CONDITIONS FOR THE USE OF EMAIL

Providers will strive to maintain the security and confidentiality of email communications but cannot guarantee this. Providers are not liable for improper disclosure of confidential information unless it results from the Provider’s intentional misconduct. Patients must acknowledge and consent to the following conditions regarding the use of email communications:

a) Emergency Use: Email should not be used for urgent or emergency situations. Providers cannot guarantee prompt review or response times for emails.

b) Email Content: Emails should be concise. Patients are advised to schedule an appointment for issues that are too complex or sensitive to be addressed via email.

c) Record Keeping: Emails will generally be printed and filed in the patient’s medical record.

d) Access by Office Staff: Office staff may read emails addressed to providers.

e) External Communication: Providers will not forward emails that contain patient identifiable information outside of Mid Cities Psychiatry without the patient’s written consent, except as required or permitted by law.

f) Sensitive Information: Patients should avoid using email for communication about sensitive medical information.

g) Liability for Breaches: Providers are not liable for breaches of confidentiality caused by the patient or any third party.

h) Patient Responsibility: It is the patient's responsibility to follow up or schedule an appointment if necessary, based on email communications.

3. INSTRUCTIONS

To ensure effective and secure email communication, patients are expected to adhere to the following guidelines:

a) Employer’s Computer: Avoid using an employer’s computer to send or receive emails, as employers may have the right to access such communications.

b) Patient Identification: Include your name in the body of the email to verify your identity.

c) Subject Line**: Clearly indicate the purpose of your email (e.g., medical question, billing question) in the subject line to facilitate timely and appropriate responses.

d) Email Address Updates: Inform your Provider of any changes to your email address to ensure ongoing communication.

e) Email Acknowledgment: Acknowledge any emails received from the Provider to confirm that the message has been read and understood.

f) Confidentiality Precautions: Take appropriate precautions to maintain the confidentiality of email communications, such as using secure networks and avoiding public WiFi when communicating sensitive information.

Medication Acknowledgement for Psychiatric Prescriptions

As a patient of Mid Cities Psychiatry, I agree to the following responsibilities:

1. Scheduled Appointments: To see my psychiatrist as scheduled for Psychiatric Prescription management.

2. Urine Drug Screen: To provide a urine sample upon request for a Urine Drug Screen, either at the office of Mid Cities Psychiatry or through an accredited laboratory within 48 hours of Mid Cities Psychiatry’s request. Should the Urine Drug Screen result be (1) positive for substances not prescribed or (2) negative for medications prescribed by a medical professional engaged in my care and treatment, Mid Cities Psychiatry reserves the right to decline any further psychiatric prescriptions.

3. Payment of Fees: To pay all office fees at the time of my visits before any service or prescription is rendered.

Medication Acknowledgement for ADD

As a patient at Mid Cities Psychiatry, I agree to comply with the following requirements for my ADD treatment:

1. Monthly Psychiatrist Visits: To see my psychiatrist every month to maintain my prescription for ADD medication.

2. Urine Drug Screen: To provide a urine sample upon request for a Urine Drug Screen, either at the office of Mid Cities Psychiatry or through an accredited laboratory within 48 hours of Mid Cities Psychiatry’s request. If the Urine Drug Screen results in (1) a positive test for substances not prescribed or (2) a negative test for medications prescribed by a medical professional engaged in my care, Mid Cities Psychiatry reserves the right to decline any further ADD prescriptions.

3. Annual EKG: To have an EKG performed annually by my primary care physician specifically for my ADD medication and to ensure that the results are sent to or faxed to Mid Cities Psychiatry.

4. Yearly Physical Examination: To undergo a physical examination annually by my Primary Care Physician to monitor health suitability for continued ADD medication.

5. Payment of Fees: To pay all office fees at the time of my visits before any services or prescriptions are rendered.

Medication Acknowledgement for Opiate Management

As a patient receiving treatment at Mid Cities Psychiatry, I agree to adhere to the following responsibilities:

1. Appointment Commitment: I will keep all scheduled appointments with the provider and their assistant and arrive on time.

2. Conduct: I will conduct myself courteously in the physician's office or clinic.

3. Urine Drug Screen: I will provide a urine sample upon request for a Urine Drug Screen, either at the office of Mid Cities Psychiatry or through an accredited laboratory within 48 hours of the request. If the Urine Drug Screen is (1) positive for substances not prescribed or (2) negative for medications prescribed by a medical professional engaged in my care and treatment, Mid Cities Psychiatry has the right to decline any further psychiatric prescriptions.

4. Payment of Fees: I will pay all office fees at the time of my visits before any service or prescription is rendered.

5. Substance-Free Requirement: I will not arrive at the office intoxicated or under the influence of drugs. If I do, the staff will not see me, and I will not be given any medication until my next scheduled appointment.

6. Medication Security: I will not sell, share, or give any of my medication to another person. I understand that mishandling my medication is a serious violation of this agreement and will result in termination of my treatment without recourse for appeal.

7. Medication Safety: I understand that using buprenorphine/naloxone (Suboxone) if addicted to opioids could cause severe withdrawal symptoms, and stopping buprenorphine could also cause opiate withdrawals.

8. Behavioral Expectations: I will not deal, steal, or engage in illegal or disruptive activities in or around the doctor’s office.

9. Medication Dispensation: My medication (or prescriptions) will only be given during regular office visits. If I miss an appointment, I will not receive medication until the next scheduled visit.

10. Responsibility for Medication: I will keep my medication in a safe and secure place. I agree that lost medication will not be replaced, regardless of the circumstances.

11. Medication Sources: I will not obtain medications from any other physicians, pharmacists, or other sources without informing my treating physician. I am aware that mixing buprenorphine with other medications, especially benzodiazepines or alcohol, can be hazardous and potentially fatal.

12. Adherence to Treatment: I will take my medication exactly as prescribed by the doctor and their assistant and will not alter my medication regimen without consulting the doctor first.

13. Comprehensive Treatment Participation: I acknowledge that medication alone is not sufficient treatment for my condition and agree to participate in the recommended patient education and relapse prevention programs.

14. Treatment Compliance: I understand that my buprenorphine treatment may be discontinued, and I may be discharged from the clinic if I violate any terms of this agreement.

15. Treatment Alternatives: I am aware of the alternatives to buprenorphine treatment for opioid addiction, which include medical withdrawal and drug-free treatment, naltrexone treatment, and methadone treatment.

To Seema Kazi, MD dba Mid Cities Psychiatry,

This is an authorization to release all Personal Healthcare Information to the listed Person(s) and/or Medical Entity/Entities below.

I hereby authorize the following listed Person(s) and/or Medical Entity/Entities to receive information pertaining to my medical care including my mental health information. I understand that all information can only be given after the listed parties present a picture ID in person. I understand that I have the right to revoke this authorization at any time by sending and/or giving a written notice to Mid Cities Psychiatry. This authorization is valid indefinitely until I revoke this authorization in writing.

To Seema Kazi, MD dba Mid Cities Psychiatry,

This is an authorization of your medical information to be transferred between health care providers, health insurance companies and any other party involved in my medical care.

I hereby authorize the following facilities/hospitals and doctor(s) to release all Personal Healthcare Information to Seema Kazi, MD dba Mid Cities Psychiatry for treatment consultation and to better manage my health.

This request includes mental health progress notes, hospital summaries, echocardiogram reports, cardiac catheterization reports, laboratory reports, electrocardiograms, physician progress notes, labs, and any other healthcare information relating to my condition.

I have the right to revoke this authorization at any time by sending and/or giving a written notice to Mid Cities Psychiatry. This authorization is valid indefinitely until I revoke this authorization in writing.

A. Notifier: Mid Cities Psychiatry, 200 Westpark Way, Euless, TX 76040

Advance Beneficiary Notice of Noncoverage (ABN)

NOTE: If your insurance doesn’t pay for the item(s) or services listed below that your provider has recommended, you may have to pay. Your insurance does not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect your insurance may not pay for the A. For Any Mental / Behavioral Health Services.

What you need to do now:

1. Read this notice, so you can make an informed decision about your care.

2. Ask us any questions that you may have after you finish reading.

3. Choose an option below about whether to receive the D. For Any Mental / Behavioral Health Services, listed above.

a. Note: If you choose Option 1 or 2, we may help you to use any other insurance that you might have.

This notice gives our opinion, not an official insurance decision.

If you have other questions on this notice, please call your insurance customer service.

NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to your insurance company, your health information on this form may be shared with your insurance company. Your insurance company will keep your health information confidential.

NOTE: Your health information will be kept confidential. Any information that we collect about you on this form will be kept confidential in our offices. If a claim is submitted to your insurance company, your health information on this form may be shared with your insurance company. Your insurance company will keep your health information confidential.

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