Due to the fact that insurance benefits are varied and constantly changing, we have the following office policy regarding payment:
I hereby authorize payment directly to Behavioral Medical Center - Troy for any medical services performed from the insurance company information that I provide. I shall be legally responsible for any out of pocket costs, such as co-pays, deductibles, and services that are not a covered benefit under the policy. I understand that Behavioral Medical Center - Troy will bill as a courtesy, and if my insurance company does not pay within 45 days, that I may be billed.
I authorize Behavioral Medical Center - Troy to release any medical information requested by my health insurance company to process a claim.
When possible, our staff will assist you in determining what your benefits are, but because we don’t always receive clear information from insurance companies, sometimes errors are made. We ask you to verify benefit information with your insurance company. If problems arise with respect to reimbursement, we will attempt to help you resolve them. But the ultimate responsibility for the full fee for services rendered is yours.
Please Note: If you must cancel an appointment, we ask that you give us at least a 24-hour notice; otherwise, you will be charged $90.00 for the late cancellation or “no show.” Neither charge can be billed to your insurance company.
If you have any questions regarding the preceding policy, please ask one of our office staff and we will be happy to assist you.
In signing below, I am acknowledging that I understand the above policies and comply with them by accepting full responsibility for payment of services.
HIPAA POLICY
BMC Troy's Privacy Policy and HIPAA policies are available for review and download on our website at:
https://www.bmctroy.com/wp-content/uploads/2024/01/HIPPA-Privacy-Notice-1.pdf
Telepsychiatry Consent
Telepsychiatry is a form of telemedicine that allows patients to access psychiatric care using an audio-video interface. BMC utilizes Doxy.me, which is a HIPAA-compliant telemedicine platform.
Benefits of Telemedicine:
Improved access to psychiatric care by enabling a patient to remain in his/her home or office.
More efficient psychiatric evaluation and management.
Maintaining treatment schedule despite logistical obstacles.
Possible Risks of Telemedicine:
As with any medical procedure, there are potential risks associated with the use of telepsychiatry. These risks include, but may not be limited to:
-In rare cases, information transmitted may be poor resolution, which may make the video portion of the visit of lesser quality
-In very rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
By signing this form, I understand the following:
- I understand that the laws that protect privacy and the confidentiality of medical information also apply to telepsychiatry, and that no information obtained in the use of telepsychiatry which identifies me will be disclosed to researchers or other entities without my consent.
- I understand that I have the right to withhold or withdraw my consent to the use of telepsychiatry in the course of my care at any time, without affecting my right to future care or treatment.
- I understand that a variety of alternative methods of psychiatric care may be available to me, and that I may choose one or more of these at any time.
Billing of Telehealth Services:
I understand that if possible, BMC will bill my telehealth visits to my insurance company. I understand that I am responsible for any applicable deductible, co-insurance or co-pays, or for the cost of the session if it is not covered by my insurance. I also understand that the BMC Payment Policy also applies to telehealth services.
Patient Consent To The Use of Telepsychiatry
I have read and understand the information provided above regarding telepsychiatry, have discussed any questions with BMC staff (if necessary), and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telepsychiatry for my care at the Behavioral Medical Center – Troy.
Patient or Parent/Guardian Signature
INVOICE, SMS (TEXT) & EMAIL COMMUNICATION CONSENT
By signing below, I hereby authorize Behavioral Medical Center to send me SMS (text) messages to provide me updates regarding my care such as appointment Confirmations, etc. I understand that I can simply opt-out of this consent by letting Behavioral Medical Center know that I no longer wish to receive SMS (text) messages from them or by texting back the work STOP to any SMS (text) message I receive from them. I also understand that the frequency of the SMS (text) messages from Behavioral Medical Center will vary.
By signing below, I hereby authorize Behavioral Medical Center to send me emails to provide me with updates regarding my care such as Appointment confirmations, billing statements, electronic invoices, etc. I understand that I can simply opt-out of this consent by letting Behavioral Medical Center know that I no longer wish to receive emails from them. I also understand that the frequency of emails I receive from Behavioral Medical Center will vary. *If you consent please add to your emails whitelist to ensure our email messages reach your inbox.
Patient or Parent/Guardian Signature
Controlled Substance
Controlled Substance Contract
Controlled substance medications (stimulants, benzodiazepines, and tranquilizers) can be effective in the treatment of certain mental health disorders. Controlled substances are highly regulated. As such, the Behavioral Medical Center – Troy follows a stringent protocol when prescribing these medications.
Please review the following Patient Responsibilities and sign at the bottom to indicate your understanding and agreement of these policies.
Because my clinician is prescribing controlled substance medications as part of my treatment plan, I agree to the following conditions:
- I will attend appointments at the Behavioral Medical Center – Troy at the frequency deemed appropriate by my clinical team.
- I give permission to the Behavioral Medical Center – Troy to access and review my prescription history at random intervals.
- I will fully disclose all current medications both short-term and long-term to my treatment team, and will notify my prescriber of changes to my medication regimen.
- I am responsible for the medications prescribed to me. If my prescription is lost, stolen, or misplaced or if I take more than what is prescribed to me, my prescription will not be replaced.
- I give permission for my clinician to discuss my diagnosis and treatment plan with other clinicians providing my medical care.
- I will use one pharmacy for all of my prescriptions. I will register the name and phone number of the pharmacy with my clinician. Should a change of pharmacy be necessary, I will promptly notify the office.
- Refill requests from pharmacies will not be accepted.
- I agree to undergo random urine, blood or saliva testing per the protocol of the Behavioral Medical Center – Troy. The presence of illicit drugs, the absence of my prescribed medications, or failure to comply with the screening will be considered a breach of contract and may be grounds for dismissal from the practice.
- I will not request or accept controlled substance medications from any other clinician or individual while I am receiving such medications from the Behavioral Medical Center – Troy.
- I will not give, share, or sell my medications to any other person.
Patient or Parent/Guardian Signature (if the patient is a minor)
As patient is a minor, please fill out the fields below: