New Patient Forms

OFFICE HOURS

Our office is open Tuesday, Wednesday, and Friday from 11am-5pm and may be reached via phone: (804) 716 4080; email: admin@sbspsych.hush.com; fax: (804) 525 5738

Updated: June 2022

We are currently operating remotely, with our administrative staff in the office 1-2 times a week. Therefore, if you call our office number it is likely that you will need to leave a message. Our administrator is able to check the messages remotely, and will contact you regarding your message within 24-48 hours. If you are calling for an urgent or same day request, please leave us a message as well as email our office at admin@sbspsych.hush.com with your request and contact information.

URGENT CARE

We do not have any urgent care facilities. If you are in a state of emergency, please call 911 or go to the nearest hospital.

APPOINTMENTMENTS

Please contact our office by email (admin@sbspsych.hush.com) to make an appointment.

In order to make an appointment, we need new clients to fill out our electronic New Patient Form, which includes demographic information, contact information, insurance information, and a Telehealth Consent Form that must be signed prior to making an appointment with us. We will send you the form via email. Once we receive the information back, we will offer you the first available appointment date.

Dr. Saiyed does not see patients under the age of 10 years old.

We strive to give all of our patients the time that they require. For this reason, we kindly request your patience and understanding should a delay or rescheduling become necessary on your appointment date.

TELEHEALTH APPOINTMENTS

Updated: June 2022

We are currently only offering Telehealth appointments. These will be video conferences conducted through HIPAA Compliant platform Doxy.me . We will send you a message via text or email (whichever preference you indicate on your New Patient form) with a link that will connect you to Dr. Saiyed for your appointments.

CANCELLATION OR AN APPOINTMENT

In order to be respectful of the medical needs of our patients please be courteous and call (804 716 4080) or email (admin@sbspsych.hush.com) our office promptly if you are unable to attend an appointment. This time will be reallocated to someone who is in need of treatment. This is how we can best serve the needs of our patients. If it is necessary to cancel your scheduled appointment we require that you call one (1) working day in advance. Appointments are in high demand, and your early cancellation will give another person the ability to have access to timely medical care.

NO SHOW POLICY

A “no show” is someone who misses an appointment without canceling it within one (1) business day in advance. No-shows inconvenience those individuals who need access to medical care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in your medical chart as a “no show”. An administrative fee of $25.00 will be billed to your account. You will receive a letter alerting you to the fact that you failed to show for a scheduled appointment and did not cancel the appointment within one (1) business day in advance along with the bill for the administrative fee. A copy of the letter will be placed in your medical record. Three (3) “no-shows” within one (1) calendar year will result in a temporary suspension of services. In order to reinstate services, you will be required to meet with Dr. Saiyed within 30 days of the third no show letter to evaluate your situation. In the event you do not respond and/or schedule an appointment within 30 days, we will consider your patient status as terminated.

**Please note that No-Show charges are patient responsibility and will not be billed to your insurance company.

INSURANCE*** 6/16/22

It is the patient responsibility to inform our office of any changes in insurance coverage. Failure to do so could cause delay or denial of insurance payment. Patients are responsible for co-pays at time of service. If applicable, you will be billed for services not covered by your insurance (as stated in your insurance contract) by our billing department.

The out of pocket cost is $175 for an initial appointment, and $75 for every follow up appointment. Payments can be made electronically or through paper check mailed to our office.

Accepted Insurances Include: Aetna Better Health, Optima, Molina, United HealthCare, Medicaid, Medicare

We do not accept: Anthem, Virginia Premier, Cigna, Blue Cross Blue Shield,

The patient is responsible for verifying that their insurance will cover the cost of the appointment.

PAYMENTS

We accept cash, personal checks, and Venmo.

Checks should be made out to: Dr. Shama B. Saiyed, MD, PC

and mailed or dropped off at our office: 4914 Radford Ave, Suite #303, Richmond, VA 23030

Electronic payments can be made via Venmo to: @SBS-PSYCH

It is our policy to make all reasonable attempts to collect outstanding balances’ should they accrue, including, convenient payment arrangements. Following these attempts, accounts in poor standing will be outsourced to a third party for the purpose of collection.

FORMS/ LETTERS

We understand that at times, various forms or letters may be required to assist you with your healthcare needs. Our staff will be happy to complete forms and write medical letters as necessary upon your request. However, because this can be time-consuming, please allow 7-10 days for the completion of requested forms/letters.

MEDICAL RECORDS

Per HIPAA guidelines, copies of medical records must be requested in writing. To ensure your privacy, a form for release of medical information must be completed prior to receipt of these materials. All patients can request a copy of their medical records one time, free of charge. Additional copies may be requested at a cost of $0.75 per page. The law allows Medical Offices 30 days to complete requests for records. However, our medical records department puts forth every effort to respond to these requests in a timely manner.

Group homes, residential services, or law firms requesting a Medical Record must do so in writing and submit it to our office by Fax (804 525 5738) or email (admin@sbspsych.hush.com). There will be a charge for obtaining medical records.

PRESCRIPTION REFILLS & PHARMACY INFORMATION

Please inform us of which Pharmacy you use and update us if this should change. Please allow one to two business days for refill requests. We encourage our patients to review their medications prior to their office appointments and to request refills at that time, if needed.

Please note that Dr. Saiyed does not prescribe controlled substances, including but not limited to: Adderall, Ritalin, Vyvanse, and Xanax.

RECEIPT ACKNOWLEDGEMENT FORM

By signing below, I acknowledge that I have received, reviewed, understand, and will comply with the policies and procedures explained in the OFFICE POLICIES & PROCEDURES FOR PATIENTS form for the office of Dr. Shama B. Saiyed, MD. PC.

I understand that attending the appointment does not guarantee that I will be prescribed medication if seen unfit by the doctor.

GOOD FAITH ESTIMATE*** 1/1/22

Services Estimates: $75-200

Initial Appointment: $145-200

Follow up: $75-140 / appointment

Disclaimer

This Good Faith Estimate shows the costs of items and services that are reasonably expected for your health care needs for an item or service. The estimate is based on information known at the time the estimate was created.

The Good Faith Estimate does not include any unknown or unexpected costs that may arise during treatment. You could be charged more if complications or special circumstances occur. If this happens, and your bill is $400 or more for any provider or facility than your Good Faith Estimate for that provider or facility, federal law allows you to dispute the bill.

If you are billed for more than this Good Faith Estimate, you may have the right to dispute the bill.

You may contact the health care provider or facility listed to let them know the billed charges are higher than the Good Faith Estimate. You can ask them to update the bill to match the Good Faith Estimate, ask to negotiate the bill, or ask if there is financial assistance available.

You may also start a dispute resolution process with the U.S. Department of Health and Human Services (HHS). If you choose to use the dispute resolution process, you must start the dispute process within 120 calendar days (about 4 months) of the date on the original bill.

If you dispute your bill, the provider or facility cannot move the bill for the disputed item or service into collection or threaten to do so, or if the bill has already moved into collection, the provider or facility has to cease collection efforts. The provider or facility must also suspend the accrual of any late fees on unpaid bill amounts until after the dispute resolution process has concluded. The provider or facility cannot take or threaten to take any retributive action against you for disputing your bill.

There is a $25 fee to use the dispute process. If the Selected Dispute Resolution (SDR) entity reviewing your dispute agrees with you, you will have to pay the price on this Good Faith Estimate, reduced by the $25 fee. If the SDR entity disagrees with you and agrees with the health care provider or facility, you will have to pay the higher amount.

To learn more and get a form to start the process, go to www.cms.gov/nosurprises/consumers or call 1-800-985-3059.

For questions or more information about your right to a Good Faith Estimate or the dispute process, visit www.cms.gov/nosurprises/consumers, email FederalPPDRQuestions@cms.hhs.gov, or call 1-800-985-3059.

Keep a copy of this Good Faith Estimate in a safe place or take pictures of it. You may need it if you are billed a higher amount.

Referral/ Case Manager

Client Demographic Information

Patient Portal and Email Confirmation

Once you are registered in our system, you will receive a registration inviting you to join our Patient Portal. The Patient Portal can be used to cancel, confirm, or request appointments, update demographic information, submit documents, or securely contact our office. Once the appointment is scheduled, you will receive an email confirmation of the appointment. Doxyme is the service we use to conduct secure video telehealth appointments. In order to attend your appointment, all you need is the link provided in the email; once clicked it will automatically connect you to Dr. Saiyed in a secure video conference. Please make sure you access to internet and a device with a webcam by the time of your appointment. The email confirmation will include the day, date, and time of the appointment, as well as the Doxyme link to connect with Dr. Saiyed for your appointment.

Notice of Privacy Practice Patient Acknowledgment

I have received and/or reviewed this practices Notice of Privacy Practices. The notice provides details about uses and disclosures of my protected health information that may be needed by this practice, my individual rights, how I may exercise these rights, and the practices legal duties with respect to my information. understand that this practice reserves the right to change the terms of its Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by the practice. I understand that I may obtain this practice's current Notice of Privacy Practices upon request.

Release of Information

The doctor is not allowed to release information to anyone but the patient, unless the patient is under the age of 18. If you would like our office to be able to discuss results with anyone besides yourself, please indicate below:

Insurance** UPDATED 2/11/2022

It is the patient responsibility to inform our office of any changes in insurance coverage. Failure to do so could cause delay or denial of insurance payment. Patients are responsible for co-pays at time of service. If applicable, you will be billed for services not covered by your insurance (as stated in your insurance contract) by our billing department.

The out of pocket cost is $175 for an initial appointment, and $75 for every follow up appointment. Payments can be made electronically or through paper check mailed to our office.

Accepted Insurances Include: Medicare, Aetna Better Health, Optima, Medicaid FFS (DMAS), and United Healthcare.

We do not accept: Anthem, Virginia Premier, Cigna, Magellan, Aetna Commercial

Emergency Contact Information

Telehealth Consent

I agree to receive Psychiatric Mental Health Appointment as a Telehealth service. I understand that the health care practitioner, Dr. Shama B. Saiyed, is located at 4914 Radford Avenue, Suite #303 Richmond, VA, 23230, and that my appointment will not be conducted in the office stated. I understand that my appointment will be conducted remotely and virtually through Telehealth methods.

A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovisual equipment. This consent is valid until September 30, 2020 for follow-up Telehealth services with the health care provider.

I also understand that:

• I can decline the Telehealth service at any time without affecting my right to future care or treatment, and any program benefits to which I would otherwise be entitled cannot be taken away.
• I may have to travel to see a health care practitioner in-person if I decline the Telehealth service.
• If I decline the Telehealth services, the other options/alternatives available for me, including in-person services, are as follows: seek alternative providers in your community.
• The same confidentiality protections that apply to my other medical care also apply to the Telehealth service.
• I will have access to all medical information resulting from the Telehealth service as provided by law.
• The information from the Telehealth service (images that can be identified as mine or other medical information from the Telehealth service) cannot be released to researchers or anyone else without my additional written consent.
• I will be informed of all people who will be present at all sites during my Telehealth service.
• I may exclude anyone from any site during my Telehealth service.
• I may see an appropriately trained staff person or employee in-person immediately after the Telehealth service if an urgent need arises OR I will be told ahead of time that this is not available.

I also understand that my insurance will be biIled for this visit with consulting health care provider, Dr. Shama B. Saiyed, and that I may be billed for what my insurance does not cover.

I understand that if I have any questions about my billing, I will need to talk with the provider’s billing office. Therefore, by signing this consent, I am giving permission to release information to my insurance company or third party payor. I give permission for the practice to provide limited information to the billing department for billing purposes.

I have read this document carefully, and my questions have been answered to my satisfaction. I understand that this consent is valid until September 30, 2022. After this date it will need to be renewed.

By signing below, I acknowledge that I have read and understand the above information.