Office Hours and emergencies:

• Our office hours are Mon through Fri, 8 AM to 5 PM. We do not provide emergency services, crisis services, weekend and after-hours coverage. If you have a life-threatening emergency, please go to the nearest emergency room or call 911

Insurance:

• Medical expenses are patient’s responsibility regardless of insurance coverage. While we verify your benefits with your insurance company as a courtesy, a copay or coinsurance info provided by us is not a guarantee of insurance coverage or payment. Patients are responsible for knowing the stipulations of their insurance policy. If for some reason your insurance company fails to pay for services rendered and/or you are not eligible at the time the services are rendered, the patient is still responsible for payment. You also agree to take full responsibility for the entire amount due for any and all services rendered that are not covered by your insurance carrier. You are responsible to timely notify our office for any changes of insurance or demographics information. You authorize your insurance plans to pay directly to Allen Psychiatry for the services provided.

Medication refill policy:

• MD TruCare and its providers NO LONGER refill prescriptions. You are responsible for scheduling a follow-up with your provider before any prescription runs out. All refills and changes in medications are done during an office visit. We only provide treatment and medication management during an appointment. Missing appointments can disrupt your care and lead to a relapse. If for any reason you need a temporary emergency prescription refilled outside of your appointment time there will be a $20 charge and it is discretion of our provider to honor such request.

Cancellations and missed appointments:

• If you need to cancel an appointment, a 24 business hour notice is required. If you miss or cancel an appointment without a 24 business hour notice, you will be charged $75 for the missed appointment. Missed appointments CANNOT be filed with insurance. Therefore you are solely responsible for the this fee. After 3 missed appointments, we will no longer provide services unless all missed appointments are paid in full.

Medication Prior Authorization:

• There is a $20 charge for each prior authorization that our office is required to obtain. This fee must be paid before the prior authorization is processed, for medications that are not listed on the formulary list for your insurance company. We advise each patient to obtain a copy of your formulary list prior to your visit, to ensure that the medications being prescribed are covered by your insurance company, and to give you the opportunity to discuss alternatives if possible. This will help to avoid charges incurred secondary to this policy.

Scope of Services:

• At MD TruCare we do not practice Forensic or Occupational Psychiatry. We do not involve in worker’s compensation cases, divorce/child custody cases, fit for duty, disability evaluations or forms or other legal matters including testimony or reports in civil matters.

Paper work:

• There is a $150 charge for FMLA paperwork completed by your provider. Please present your paperwork to the receptionist prior to your appointment. Any letter or forms requested by the patient will be charged a preparation fees of $50 and up. It’s at your provider’s discretion to complete it or not. Prepayment is required for any paper work and may take 5-10 business days.

Returned checks:

• There is a $50 charge for any returned checks.

Medical records:

• If you need a copy of your medical record, you must give this office a signed notification from the patient and a 2 week notice. The charge for medical records is $30.

Labs:

• We may need to order labs in some cases. Please note the cost of labs is not included in your visit charges. It is your responsibility to ask the lab about their cost. You may choose any lab of your choice.

Testifying in court:

• If legal actions occur in which your physician is subpoenaed to provide testimony (such as in custody cases) you will be responsible to provide the following even if the subpoena is sent from the opposing side of the case: a.) travel expenses b.) hourly or per diem fees based on our existing fees from the time the physician leaves the office until she returns. At least 50% of the anticipated cost will be expected prior to the court appearance.

Communications:

• We routinely use phone, email and text to communicate on scheduling, billing, refills and other matters related to our services. While we exercise caution, and encrypt electronic communication on our end, we expect the electronic communication is protected on your end (such as PIN for voicemail or password for email). If you do not feel comfortable with electronic communication, or if it isn’t protected on your end, please do not schedule an appointment with us.

Confidentiality:

• MD TruCare is committed to confidentiality to the fullest extent allowed by Texas law. There are several exceptions. The following are common: a.) any evidence of child abuse (past or present) must be reported. b.) If any individual intends to take harmful, dangerous, or criminal actions against another human being or against him/herself. It is our duty to report such actions or intent to the authorities. c.) Sexual improprieties by a former therapist or psychiatrist are a criminal offense and must be reported. You have certain rights in such reporting which your physician can explain to you. d.) Certain court order / action such as custody cases, malpractice actions and criminal cases. e.) Collection of fees. If you have questions about this area, please feel free to discuss with your provider.

Danger:

• In the event that your provider, in her clinical judgment believes you to be dangerous to yourself or to someone else, by signing this consent you authorize her to contact either the person listed as your emergency contact or someone else to provide assistance through a crisis situation.

Right to withdraw:

• If a conflict arises for the client or the physician/provider, either has the right to withdraw from the treatment. If the provider feels the need to withdraw from providing treatment, she will inform client and will try to provide appropriate referrals and 30-day emergency care.