"Our patients love the fact that for every single appointment, we provide an estimate for their out of pocket expense. This practice is rare in small offices.", Mandy Larsen, Practice Manager
* Please note copay or coinsurance estimate provided by us is not a guarantee of insurance coverage or payment.
Policies (Updated 06/10/2022)
Office Hours and emergencies:
Our office hours are Mon through Fri, 7:30 AM to 5 PM. Our office is closed on all major holidays. 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
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:
Allen Psychiatry and its providers DO NOT refill prescriptions without a virtual or in-person appointment. 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/after your appointment with a provider. Missing appointments can disrupt your care and lead to a relapse.
If you are on a controlled substance, we have the right to deny or hold your prescription until drug screening (UDS) is complete as ordered by your provider.
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 this fee. After 3 missed appointments, we might not provide services unless all missed appointments are paid in full.
Medication Prior Authorization:
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 on your pharmacy benefits/policy.
Scope of Services:
We do not practice Forensic or Occupational Psychiatry. We do not get involved 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.
We do not treat unstable actively psychotic patients with Schizophrenia and/or Acute Psychotic Disorders. Such patients require case managers and higher level of care. We do not provide social services and case management.
There is a $100 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 up to 5 business days.
There is a $50 charge for any returned checks.
If you need a copy of your medical record, you must give this office a signed authorization from the patient.
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.
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.
Allen Psychiatry 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.
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.
HIPAA Notice of Privacy Practices
IF YOU HAVE ANY QUESTION AND / OR CONCERNS REGARDING ETHICAL ISSUES, THEY MAY BE DIREDCTED TO THE FOLLOWING CONSUMER HOTLINE AT 1-800-942-5540.
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.
This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health services.
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health information, as necessary, to a home health agency that provides care to you. For example, your protected health information may be provided to a physician to whom you have been referred to ensure the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical students that see patients at our office. In addition we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the regulations of Section 164.500.
Other Permitted and Required Uses and Disclosures Will be made only with your consent, authorization or opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Following is a statement of your rights with respect to your protected health information
You have the right to issue and copy your protected health information. Under Federal law, however, you may not inspect or copy the following records; psychotherapy notes, information compiled in reasonable anticipation or, or in use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purpose of treatment, payment or healthcare operations. You may also request that any part of your protected health information not to be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply
Your physician is not required to agree to a restriction that you may request. If your physician believes that it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communication from us by alternative mean means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny your request for amendment, you have the right to file to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.