Policy and Procedure
Guidelines:

Medication Management

Refills should be requested on regularly scheduled visits. Medication adjustments and changes can only be made during scheduled visits, unless there are medication side effects that necessitate changes before a visit can be scheduled.

Fees and Billing

Payment is due at the time of service. Please review below pre-authorized payment agreement /credit card on file policy.

SANA reserves the right to provide diagnosis and treatment based on clinical judgment and information provided, fees are not contingent on receiving specific diagnosis, prescriptions, or treatments.

PRE-AUTHORIZED PAYMENT AND AGREEMENT/CREDIT CARD ON FILE

Insurance co-payments or our self-pay rates, if any, are due on the day of a scheduled appointment. I understand that I am ultimately responsible for the fees outlined in the “Policies and Consent” form and this will be charged to my credit card on file with SANA Psychiatric Associates (Please refer to the excerpt below for reference on fees that could apply)

I understand that I am in full control of my payment method, and I may change my payment method on file a day prior to a scheduled appointment.

By signing this form, you give SANA Psychiatric Associates permission to debit your account with the credit card information stored on file. You affirm you are an authorized user of the credit card whose number and expiration date supplied, you do authorize its use for all fees incurred and agree you have read pre-authorized payment agreement/credit card on file.

For in-network services, I will submit claims on your behalf as a courtesy, but there is no guarantee that your insurance will pay. You are responsible for full payment, whether your insurance company ends up paying partially, or not at all, for services rendered.

You are financially responsible for all charges, whether or not:

1. Insurance pays for any services
2. We decide to proceed with treatment
3. Treatment is successful, for which there cannot be any guarantee

• I hereby authorize my insurance benefits to be paid directly to Alice Sanchez MD PA and I recognize my responsibility to pay for all non-covered services, including any additional cost incurred in collecting these amounts.
• I also authorize SANA Psychiatric Associates to release any and all information necessary in my financial or medical records including diagnosis, test results to my insurance carrier or health plan, their agent and independent contractor in order to process my insurance claim, In the event that my insurance fails to make a payment to Alice Sanchez MD PA, I understand that I am ultimately responsible for the fees, and this will be charged to my credit card. This consent applies to all records created in the course of and relating to my treatment and for the purpose of reimbursement for treatment.
• I understand that if I choose to self-pay, payment is also due on the day of the appointment. Our fees are $275.00 for a new evaluation and $175.00 for follow-ups. There is a $30.00 fee for bounced checks and a $15.00 fee for declined credit cards. Unpaid balances are charged a late fee of $40.00/month. These fees are subject to change.
• I understand that if I fail to pay for the services received, that not only may my services be terminated, but in addition all billing information including name, address, place of employment, dates of service received, etc., may be given to a professional collection agency to use in their process of collection.
• I further understand that if my account is placed for collection, I will be responsible for the fee charged by the collection agency and any attorney or court fees assessed.

Medical records, work excuses, school notes, calls to employers, return to work letters, etc. will be provided on a fee basis. The fee will be based on time spent preparing the requested information.

We DO NOT do FMLA/Disability paperwork. In the rare case that we fill out FMLA/Disability paperwork, there will be a charge of $100.00 as we will not be able to bill your insurance or your employer for that.

Blood work may be monitored occasionally depending on the medication regimen, Orders will be sent to either LabCorp or Quest. You are responsible for the lab charge/payment/co-payment and release SANA Psychiatric Associates from any liability secondary to this.

• I understand that any changes to my insurance I will notify the office within 5 business days of my appointment, or the appointment will be self-pay.
• I understand that all information obtained in regard to my insurance coverage is not a guarantee of payment by my insurance company. The amount collected at the time of service is an estimate.
• I understand I am ultimately responsible for any and all balances on my account.
• I understand that Doctors do NOT write support animal letters.
• I understand that SANA Psychiatric Associates has the right to terminate any patient who is non-compliant with office policies/medications. This includes multiple no shows without advance notice (work meetings are not excused absences) showing up late to appointment on a regular basis and losing or throwing away medications.

Other fees you may be responsible for

• Prescription refills outside of session time
• Time spent obtaining prior authorizations
• Coordination of care for emergencies, hospitalization, intensive outpatient, residential treatment, rehabilitation, etc.
• All forms (insurance, worker’s compensation, school, employer; doctor’s notes, letters, or reports) and chart reviews not filled out in session
• Testimony in court, at depositions, administrative hearings, board reviews, and all time required for preparation and travel, whether requested by you or ordered by a court, board, government agency or other legal authority.

PATIENT RIGHTS/ DISCHARGE:

Non-voluntary discharge from treatment: A patient may be terminated via a non-voluntary discharge letter if: 

(A) the patient exhibits physical violence, physical or emotional intimidation, verbal abuse of any kind, and/or patients or family members carry weapons or engage in illegal acts of any kind. Abusive messages or phone correspondence may also be grounds for non-voluntary discharge. 

(B) The patient refuses to comply with stipulated clinic rules, refuses to comply with treatment plans/recommendations, or does not make a payment and/or payment arrangements in a timely manner. 

(C) The patient repeatedly cancels, late cancels, or no shows for appointments. A patient may choose to terminate treatment at any time of their own accord and a 30-day supply of most medications will be provided with some exceptions (to be discussed with your Provider).

APPOINTMENTS AND CANCELLATIONS

We reserve your appointment time to give you our full attention and care. If you need to postpone your appointment, you are required to give at least 24 hours in advance, failure to cancel will result in their credit card on file being charged $75 as we are unable to bill insurance companies for missed appointments.

Cancellations impact 3 individuals:

1) Yourself – You limit your ability to reach your goals

2) Your Provider – Time has been made in the provider’s schedule specifically for you

3) Another patient – We are unable to fill your appointment slot with others that are needing to get on the schedule when short notice is given.

If you are more than 10 minutes late to your appointment, you may be asked to reschedule your visit, and the visit will be considered a missed appointment. Emergencies and extenuating circumstances will be considered on a case-by-case basis. Please note insurance will not reimburse for missed appointments or late cancel appointments.

COMMUNICATION:

I (the patient) consent to receiving SMS text messages for appointment reminders as well as for links for Doxy.me for appointments. Communication in your patient portal in OnPatient (DrChrono patient portal)

EHR is preferred as it is HIPAA compliant and secure. You can ask questions about appointments, medications, and request refills in the portal and also view your visit summaries and upcoming appointments. Medications changes are addressed only during patient appointments, but please do not hesitate to reach out to us by phone about concerns regarding medication side effects.

If your communication is urgent or confidential, please call SANA Psychiatric Associates at (214) 705-2246. Voicemails are checked regularly, and every attempt is made to return calls within one business day. Please note calls after 5 pm or at the weekend will be returned on the next business day.

All communication and clinical treatment will be documented in the patient chart. Both the law and the standards of the profession require such. You are entitled to receive a copy of these records unless I believe that seeing them would be emotionally damaging. If this is the case, I will be happy to provide the records to an appropriate mental health professional of your choice or to prepare an appropriate summary instead. Because client records are professional documents, they can be misinterpreted and can be upsetting. If you wish to see the records, it is best to review them with me so that we can discuss their content.

If you or your child is seeing me for medication management only:

• You will contact your/your child’s therapist first for any emergency or crisis, unless it may be medication related
• You will inform me if you/your child are/am considering stopping therapy, or have stopped
• You/your child will see me through tele-medicine no less than every three months for follow-ups.

PATIENT NARCOTIC AND ADHD MEDICATIONS IF PRESCRIBED

• I understand that the medication I am prescribed for ADHD is a Class II Narcotic and the medication I am prescribed for sleep and anxiety is a Class IV narcotic.
• I understand that the medication cannot be refilled before thirty (30) days.
• I understand that if I lose my prescription, I will have to wait until the last due date from the original due date the last prescription was written for a refill.
• I understand the medication is for my use only and cannot be shared with anyone else.
• I understand that I am subject to random drug testing.
• I understand that I will only take the medication as prescribed.
• I understand that I cannot take illegal street drugs with this medication and if illegal drugs are found in my system with drug testing this medication will not be renewed by my provider.

EMERGENCIES AND AFTER-HOURS WEEKENDS OR HOLIDAYS

If you/your child requires immediate assistance, are feeling unsafe, or are in an emergency or a crisis situation please do not wait for us to return your call, please call 911 or go to your nearest emergency room.

You may also call the North Texas Behavioral Health Authority (NTBHA) Mental Health Support line at 1-833-251-7544 or the LifePath Systems Crisis Line 1-877-422-5939 which is available 24 hours a day, 7 days a week, 365 days a year.

Note: We do not have admitting privileges, nor are we affiliated with or on staff at any hospital.

Should we deem more intensive services are needed than we can provide, we will do my best to ensure safety and obtain the appropriate level of care, but we cannot provide that care directly and cannot guarantee the receipt or quality of care that others provide.

Risks and benefits of psychotherapy:

Psychotherapy has both benefits and risks. Possible risks include the experience uncomfortable feelings (such as sadness, guilt, anxiety, anger, frustration, loneliness, or helplessness) or the recall of unpleasant events. Potential benefits include a reduction in feelings of distress, better relationships, better problem-solving and coping skills, and resolution of specific problems. Given the nature of psychotherapy, it remains an inexact science and no guarantees can be made regarding the outcome.

CONFIDENTIALITY

There is no guarantee of confidentiality under the following conditions:

• If we suspect you/your child are/is in imminent danger of harm to self or others, or a child or elderly person is being abused or neglected (as we are mandated reporters)
• If a court orders a release of information
• If you initiate a malpractice lawsuit, or a billing dispute with a financial institution
• If your insurance company requests to review your/your child’s case
• If you pay by credit card, our name will appear on your credit card statement
• If you do not pay your bill, your balance due statement (including diagnostic and procedural codes) may be sent to a collection’s agency or other responsible party
• Between your provider here and our administrative staff, or colleagues with whom I consult professionally

Please note, rates and policies are subject to change and will be re-evaluated annually.

Notice concerning complaints

Complaints may be reported to:

Texas State Board of Medical Examiners ATTN Investigations

1812 Centre Creek Drive, Suite 300

PO Box 149134

Austin, TX 78714-9134

Please note that these policies and procedures are subject to change, and the most up-to-date version will always be available on our website. By choosing to engage in our mental health services, you agree to abide by these policies and procedures.

If you have any questions or concerns regarding these policies, please do not hesitate to reach out to us. We are here to provide the best possible care and support for your mental health needs.