Daya Mental Health and Wellness

New Patient Forms

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Insurance Information (We DO NOT accept medicare or medicaid)

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      Medication List - We do NOT prescribe benzodiazepines (Xanax/Ativan/Klonopin Etc) at our practice - Only for patients requesting medication management appointments should complete this section

      Legal Guardianship (Adult or Child)

      For minor client: Is there any custody agreement in place?

      For adult clients: Are there any guardianship agreements in place for you?YesNoNot applicable

      I understand that if there is a custody or guardianship agreement in place that I will provide Daya Mental Health and Wellness with a copy of the agreement for the clients chart, which will include a statement of medical decision making permissions.

      Patient Consent for Treatment


      Privacy and Release of Information

      Our practice values and upholds the importance of your confidentiality. In addition to your rights as a patient, our practice has duties to protect your confidential information and inform you of changes to protection measures. We are required by law to maintain the privacy of confidential information and provide you with notice of our legal duties and privacy practices with respect to such information. I am required to abide by the terms of this Notice currently in effect. There are, however, certain situations in which we must, by law, communicate your confidential information. Here is list of those circumstances:

      We have reason to believe you are a danger to yourself or another person or persons

      We become aware of abuse to child, elder or developmentally disabled person

      We are under court order to release information

      Subpoena of treatment records by an attorney. (We will not immediately release records upon receipt of a subpoena, but will do everything in our power to keep your records private. Usually a court order will be required. You have up to fourteen (14) days to obtain a protective order from the court to avoid disclosure of your records)

      If you are applying for your health insurance benefits, we may be required to provide information to your health plan, including some or all of your patient chart, in order for them to approve payment. By signing the "Acknowledgement of Policies and Procedures" you consent to release that information to your health plan.

      If you are party to child custody litigation at any time in the future, the court may order release of information about your treatment.

      In some circumstances, as provided by the state law of North Carolina, information about your may be exchanged with other health care professionals involved in your treatment.

      Disclosure and Confidentiality

      Confidential information may be released for payment and health care operations only to health insurance plans and their agents, as well as business associates of the practice. The definition of a health insurance plan does not include life insurance companies, automobile insurance companies, or workers’ compensation carriers. These are not covered under HIPAA. If you would like information submitted to one of these companies, an authorization will be required, unless it is already mandated by state or federal law.

      The following routine situations necessitate the use of your information:

      For Treatment - We may use information about you in order to provide you with proper medical treatment or services. Treatment is when we provide, coordinate, or manage your healthcare and other services related to your health care. An example of treatment is when we consult with another health care provider, such as your primary care provider.

      For Payment - We may use and disclose information about you so that the treatment and services you receive can be collected from an insurance company, or a third party (including a collection agency if necessary). For example, we may give your health insurance plan information about services you received at the practice, so your health insurance can reimburse the services. We may also tell your health insurance plan about a treatment you are going to receive, in order to obtain prior approval or determine if your plan will cover the treatment.

      For Health care Operations - We may use and share information about you for administrative functions necessary to run the practice and promote quality care. We may share information with business associates who provide services necessary to run the practice, such as transcription companies or billing services. Also, we may permit your health insurance plan or other providers to review records that contain information about you to assist them in improving the quality of service provided to you.

      Communicating with You and Others Involved in Your Care - This practice may contact you to provide appointment reminders, information about treatment alternatives, or other health-related benefits and services that may be of interest to you. Overall, it is our mission to honor confidentiality of our patients with utmost regard. Information disclosed will be directly relevant to such person’s involvement with your care or payment related to your care. In emergencies or other situations in which you are unable to indicate your preference, we may need to share information about you with other individuals or organizations to coordinate your care or notify your family.

      Special Circumstances in Release of Private Information

      The following special circumstances necessitate the use of your information: 


      As Required By Law - We will disclose information about you when required to do so by federal, state or local law. For example, we may release information about you in response to a valid court subpoena.

      Health Oversight Activities - We may disclose information to a health oversight agency for activities authorized by law. For example, these oversight activities include: audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.

      For Judicial or Administrative Proceedings - If you are involved in a court proceeding, and a request is made for information about the professional services that you have received within our practice and the records thereof, such information may be privileged under state law. We will not release information without the written authorization of you or your legal representative, or in instance of issuance. This may also be the case in the instance of a court subpoena, which requires the provision of such information, which you have been properly notified. In response, you have not opposed the court subpoena within the legally specified format and time frame, or in the instance of the issuance of a court order compelling us to provide Protected Health Information (PHI). This privilege does not apply when you are being evaluated for a third party or where the evaluation is court-ordered. You will be informed in advance if this is the case.

      To Avert Serious Threat to Health or Safety - We may disclose your confidential mental health information to any person without authorization if we reasonably believe that disclosure will avoid or minimize imminent danger to your health or safety, or the health or safety of any other individual. These disclosures may be to law enforcement officials to respond to a violent crime or to protect the target of a violent crime. For example, threats of harming another individual may be reported to appropriate authorities.

      Worker’s Compensation - If you file a worker's compensation claim with certain exceptions, we must make available at any stage of the proceedings, all PHI information in our possession that is relevant to that particular injury in the opinion of the North Carolina Department of Labor and Industries, to your employer, your representative, and the Department of Labor and Industries upon request.

      Public Health Risks - We may disclose information about you for public health activities. These activities generally include, but are not limited to, the following: a. To prevent or control disease, injury, or disability
b. To report child abuse or neglect
c. To report adult and domestic abuse
d. To report reactions to medications or problems with products e. To notify people of recalls of products they may be using f. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition g. To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

      Law Enforcement - We may release information about you if asked to do so by a law enforcement official: a. In response to a court order, subpoena, warrant, summons, or similar process
b. To identify or locate a suspect, fugitive, material witness, or missing person
c. If you are suspected to be a victim of a crime, generally with your permission d. About a death we believe may be the result of criminal conduct e. About criminal conduct at the hospital f. In emergency circumstances involving a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime

      Other uses and disclosures of information not covered by this notice or the laws that apply to our practice will be made only with your written permission. If you provide this practice with specific permission to use or disclose information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures that have already been made with your permission and that we are required to retain our records of the care that we provided to you.

      Changes to Notices

      We reserve the right to revise or change provisions on this Notice. We will make the new Notice provisions effective for all confidential information we maintain. Our clinic will promptly revise and distribute Notice whenever there is a change to the uses or disclosures, your rights, and our duties, or other privacy practices stated in this Notice. We will mail updates of our notice to all active patients. Patients who are inactive at the time of mailing may receive an updated copy at their next scheduled appointment.

      Patient Records

      An electronic record is kept of services you receive in this office. You have a right to see the record and receive a copy of it upon request. You may ask that factual errors in the record be corrected. You may authorize in writing that copies of the record be released to medical providers you designate at no cost, or may be picked up in person at your expense for a fee, according to charges stipulated by the state law of North Carolina. Under certain circumstances where seeing the record may put a patient or other person at risk, we may redact certain information in the record and/or require that you review the record in consultation with another healthcare provider. You may receive an accounting of non-routine uses and disclosures of your record. After a request is made, we have 30 days to produce records

      Concerns for Safety

      If as a patient, you are deemed a safety concern for self and/or others or are assessed during evaluation to have declined physically and emotionally to the point that self-care is an issue, it is our legal obligation to inform mental health deputies or officials for further action which may include detainment or acute psychiatric hospitalization. In such events as noted above, your confidentiality and your records will be released to officials and the aftercare facility.

      Right to Terminate Treatment

      In certain rare circumstances, our clinic may reserve the right to terminate your treatment at Daya Mental Health & Wellness. We will immediately notify you if this occurs. In the event of misuse of prescriptions or in the case that your treatment is no longer seen as therapeutic, such that our options are maximized and further rapport and agreement in your care is compromised, then we may terminate our relationship. We will do our best to recommend further referrals. We also reserve the right to terminate your privileges as patient in the event of repeat nonpayment. We will do our best to accommodate any financial difficulties through payment plans if concerns are discussed with us. We also reserve the right to terminate treatment with repeat missed appointments.

      Payment

      As a patient, you must be aware of current established payment policies. Prior to your established visits, please thoroughly read and acknowledge our established payment guidelines as outlined below. Acceptable methods of payment include cash and credit card. The fee schedule in place for patients making payment directly to the clinic without a third party payor source (Insurance). Fees are subject to change, however, any changes will be discussed with you.

      Zero-Tolerance Policy

      All our staff members are trained and dedicated to serve you and you will be treated with courtesy and respect at all times. In return, we ask that you and anyone that you bring with you to the practice office treat our administrative and clinical staff with the same courtesy and respect.

      We have a ZERO TOLERANCE approach to any verbal, aggressive and violent abuse and behavior towards our staffs or other patients. We respectfully advise you that abuse and/ or violence will not be tolerated.

      If a patient or anyone a patient brings with them to the clinic, is abusive, aggressive or violent towards our staffs and/ or other Patients the police may be called and may result in you being removed from our clinic list.

      Medication, Lab and Controlled Substance Policies

      Medication Policies

      Medications will not be refilled outside of scheduled appointments. Should an appointment be missed a bridge of medication may be needed to allow patient to get to the next scheduled appointment. This will be given at the discretion of the provider.

      No medications will be called in on the weekends.

      Controlled substances will NOT be filled outside of scheduled appointments.

      No controlled substances will be provided without an IN PERSON appointment with a provider per DEA guidelines.

      Controlled substances require frequent monitoring which includes appointments every month for MAT and every 3 months for other medications. Clients will be subject to random urine drug screens and/or pill counts as requested by the provider.

      Sublocade and Vivitrol medications left at our practice over 30 days will be disposed of unless prior arrangements have been made.

      Medication refills should last until your next appointment with us. Should you need a refill please call the office. We do not respond to faxed requests from pharmacies as we get hundreds a day and often times they are incorrect. The patient must call the office and either leave a message, call the office, send an email or request through the portal. Then check with your pharmacy for the status of your refill.

      Should you need a medication change, contact the office to discuss. If a client alters their dose of medication and takes a larger dose than is prescribed, it can potentially be dangerous for the client. Any abuse of a controlled substances will not refilled early and a discussion between provider and client will determine the need for a discontinuation of medication or a higher level of care.

      Labs

      At times certain medications will require laboratory monitoring. If labs have been ordered and a client refuses to obtain these labs, our practitioners cannot safely continue to prescribe these medications. Medications will be discontinued and alternate medications may be offered. This includes urine drug screens.

      Controlled Substances

      Controlled substance are used for several different conditions in psychiatry. The goal will be to use a minimum amount of these medications and titrate off or down when applicable. Multi-state narcotic reports will be monitored and a controlled drug contract may be required. Should multiple providers be located on drug report, client will be taken off that medication and/or discharged from practice.

      Urine drug screens will be ordered for monitoring in office. Should any drug screen test positive, we will send for a conformation test to be completed at an outside laboratory and a separate bill will be charged by their company.

      No controlled substance will be sent in outside of appointments. Clients must attend their appointments.

      Should a client have issues with medication abuse or positive drug screens, the provider reserves the right to refer to a higher level of care, require more frequent appointments, require pill counts, require smaller quantities of medications at one time and/or discharge from practice.

      We DO NOT prescribe benzodiazepines at our practice.


      Records, Forms, Paperwork

      Providers at Daya Mental Health and Wellness do not provide letters for emotional support animals

      We do not complete disability forms but will send records with a proper request and release. Fees for records for disability determination will be paid by the Social Security Administration

      We will complete paperwork for FMLA, letters for accommodations and school requests provided the client has been an active patient of Daya Mental Health and Wellness and the particular provider for at least 3 months. A $25.00 fee for form completion will be charged to the patient. Insurance will not cover this charge. Please allow 14 days for completion.

      Providers at Daya will not provide letters of recommendations to the courts on behalf of clients as we believe this can be damaging to the provider/ client relationship. We will provide a letter of "proof of attendance" or "proof of drug screen and results" if the patient requests. $25.00 fee will apply. Please allow up to 14 days for completion.

      Record requests can be made to the front office. $25.00 fee applies.

      Paperwork, Forms, Letters (ESA, Disability, Court)

      Providers at Daya Mental Health and Wellness do not provide letters for emotional support animals

      We do not complete disability forms but will send records with a proper request and release. Fees for records for disability determination will be paid by the Social Security Administration

      We will complete paperwork for FMLA, letters for accommodations and school requests provided the client has been an active patient of Daya Mental Health and Wellness and the particular provider for at least 3 months. A $25.00 fee for form completion will be charged to the patient. Insurance will not cover this charge. Please allow 14 days for completion.

      Providers at Daya will not provide letters of recommendations to the courts on behalf of clients as we believe this can be damaging to the provider/ client relationship. We will provide a letter of "proof of attendance" or "proof of drug screen and results" if the patient requests. $25.00 fee will apply. Please allow up to 14 days for completion.

      Record requests can be made to the front office. $25.00 fee applies.

      PHONE, TEXT, EMAIL CONTACT CONSENT

      I fully consent to and authorize Daya Mental Health and Wellness or any of its automated systems to contact me via phone (including to my cellular phone by way of phone call or text message) in relation to any services received from Healthcare Provider or any services planned to be received from Healthcare Provider (including any billing items or appointment reminders). I understand that these methods of communication increase my risk of exposing my private health information especially when texting or emailing.

      HIPAA Privacy Rule of Patient Authorization Agreement

      Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a))

      I understand that as part of my healthcare, this Practice originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as:

      • a basis for planning my care and treatment;
      • a means of communication among the health professionals who may contribute to my health care;

      • a source of information for applying my diagnosis and surgical information to my bill;

      • a means by which a third-party payer can verify that services billed were actually provided;

      • a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals.

      Upon request I will be provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

      I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this Practice’s notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me.

      Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations

      I understand that:

      • I have the right to review this Practice’s Notice of Information practices prior to signing this consent;
      • that this Practice reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I’ve provided, if requested;

      • I have the right to object to the use of my health information for directory purposes;

      • I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this Practice is not required by law to agree to the restrictions requested;

      • I may revoke this consent in writing at any time, except to the extent that this Practice has already taken action in reliance thereon.

      Financial Policies

      As a patient, you must be aware of current established payment policies.Acceptable methods of payment include cash and credit card. Fees are subject to change, however, any changes will be discussed with you. Payment for mental health services is due in full at the time of service unless prior arrangements have been made. Daya Mental Health and Wellness will file a claim with your insurance and make every effort to collect fees from insurance company per our contract with each individual insurance provider. If we exhaust our efforts to obtain payment from your insurance company and are unable to obtain payment within 60 days, the responsibility then returns to the client to pay any unpaid balance and the client can then seek reimbursement from the insurance company.

      All unpaid balances will be sent to collections after the balance reaches 60 days past due and no attempt has been made by client to make payment. If arrangements are not made to pay past due balances, clients will be discharged from the practice with referrals to other providers. Upon turning over balance to collection agency, a fee of 50% of total balance owed will be added to bill for collection and administrative charges. All charges for disputed charges from client will also be added to clients bill balance for collections.

      Should a client ask their bank for a reversal for a charge that they have made at our practice and the practice is found to win the chargeback claim, a charge of $50 will be added to the clients bill for preparation of disputing fees.

      All clients that are attending telehealth or in person visits will be required to keep a credit card on file through or payment system Helcim.

      For appointments, clients will be charged the MONDAY/ TUESDAY after your appointment for any copay and/or coinsurance. Should your credit card be declined, a notification or call will be made to you to replace your card on file. Should a client refuse to pay their balance or keep a card on file, we will refer client to a different practice. If a client has a financial hardship, please speak to staff about payment arrangements.

      Missed Appointments and Late Cancellations

      Failure to keep your scheduled appointment will result in a fee of $100 for initial visits and $100 for follow-up visits, unless you cancel at least forty-eight (48) hours prior to the appointment time. In emergent circumstances, please immediately contact office and if the circumstance is determined to be dire, this fee will be waived. This fee cannot be waived more than once. Showing up late (more than 10 minutes) for an appointment may result in cancellation and being charged a late cancellation fee of $100.

      Clients with two no shows will be discharged from our practice with a list of referrals to other providers. We will prescribe a one month supply of all non controlled medications for clients that are discharging. Controlled medications will not be provided for clients that have missed appointments

      Understanding Health Insurance

      Below you will find information to help you understand insurance terminology and help you determine your costs associated with your care. We always recommend that you call your insurance company and have a conversation with them regarding what your plan pays for and what it does not. You are responsible for determining if we are in network with your specific plan and if your plan covers the care/ procedures which we provide. You are responsible for determining if your plan covers telehealth or not. I understand that I have had the opportunity to contact my insurance company to investigate what benefits I have and what my costs will be for care. I understand that I am responsible for all costs that my insurance company does not pay regardless of the reasoning behind their decision. Once my insurance company pays my bill, I understand that I must pay any remaining balance from deductibles, copays, copayments or denials. Should my insurance not respond to billing or deny any charges, after 60 days of attempting to bill insurance for my charges, that all unpaid balances will be due in full. I understand that I will need to keep a credit card on file for these charges and I agree to allow Daya Mental Health and Wellness and their billing company to charge these fees. I understand and agree to all of the above information:

      It all starts with your health insurance plan.

      • When you purchase health insurance, you are entering into a contract with the health insurance company; you buy the plan and the company agrees to pay for some portion of your medical costs.
      • There are a few ways your health insurance plan will share costs with you: deductibles, co-pays, co-insurance. It is important that you understand how these will apply with various healthcare services you receive.
      • There are lots of health plans to choose from and they offer a wide variety of coverage options. Generally, the less expensive plans have more restrictions and provide less coverage. You may pay less up front in premiums, but may be required to pay a larger portion of your medical costs. Keep this in mind as you determine the plan will best meet your healthcare and financial needs.
      • Your health plan sets the rules: what is covered, how much coverage you have for each service and supply, which providers are "in-network" vs. "out-of-network," any special rules that restrict access to coverage, and generally what your portion of the bill will be for each service.
      • When a healthcare provider is out-of-network with a health plan it means they do not have an agreement with that plan. Some health insurance plans provide only limited or NO coverage when you access care from an out-of-network provider. This means the bill you receive from an out-of-network healthcare provider could be much higher than if you received that same service from an in-network provider.

      Information you need to understand from your health insurance plan BEFORE you access healthcare at ANY provider:

      Before you receive services from any healthcare provider, see if that provider is in-network and how your plan will cover costs for the type of service you will be receiving. You can do this in a few different ways:

      • Call your health insurance plan. You can typically find their number on the back of your insurance card.
      • Use your health plan’s website. Many offer interactive web tools to help you understand your coverage.
      • Use your health plan’s mobile app. Many offer mobile apps to help you understand your coverage.

      Check your plan against what type of service you will be receiving (e.g., physical therapy, immunizations, primary care visit, psychiatry care, etc.) and where you would like to be seen.

      Try to determine the answers to these types of questions:

      • Is this healthcare provider in-network?
        • If not, how can I find an in-network provider?
        • If I choose to see this provider anyway (out-of-network), what will my cost be?
      • Does my plan provide coverage for this service?
        • Are there limitations or exclusions to my coverage for this service?
        • Does my plan require a Prior Authorization or Referral?
        • Does my plan limit the number of visits that I am entitled to?
        • If I am given supplies as part of my care, will they be covered?
      • Will I need to pay a deductible?
        • If so, how much is my deductible?
        • When does my deductible reset each year?
        • Do I have a different deductible for in-network and out-of-network providers?
      • Will I need to pay a co-payment or co-insurance? If so, how much?
      • Is my prescription plan different than my medical plan?
      • Does my plan include dental coverage?

      Note: If you will be receiving lab work, make sure you check with your health insurance plan to see how they will process bills

      Understanding the Difference Between EOBs and Bills

      Medical bills are sent from healthcare providers. They may include very detailed information about your specific diagnosis and treatment/testing. Anyone viewing medical bills could have a very clear sense of your diagnosis and treatment plan.

      Explanation of Benefits (EOBs) are sent by your health insurance plan. They have much less detail. EOBs do show where you were seen and a general descriptor of services (e.g. "physical therapy" or "lab work").

      You have control over where bills and EOBs are sent and should proactively make sure they are going to the address you want them to. To control where bills are sent, make sure the address we have on file is accurate. To control where your EOBs are sent, contact your health insurance plan.

      Common Definitions

      Co-insurance: The percentage of each bill you must pay out-of-pocket.

      Co-payment: The fixed amount of each bill you must pay out-of-pocket. The co-pay is usually due at the time of service.

      Coordination of Benefits (COB): When two or more insurance plans cover the same person, Coordination of Benefits is used to determine which plan pays first.

      Covered Benefits: The health care items or services covered under a health insurance plan. Covered benefits and excluded services are defined in the health insurance plan's coverage documents.

      Deductible: The amount you pay for covered health care services before your insurance plan starts to pay. With a $300 deductible, for example, you pay the first $300 of covered services yourself. The deductible may not apply to all services. Typically, health plans will have a separate deductible for in-network vs. out-of-network providers.

      Durable Medical Equipment: Equipment and supplies ordered by a health care provider for everyday or extended use. Coverage for DME may include: medically-necessary splints, wheelchairs, crutches or blood testing strips for diabetics.

      Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO. It generally won't cover out-of-network care except in an emergency. An HMO may require you to live or work in its service area to be eligible for coverage. HMOs often provide integrated care and focus on prevention and wellness.

      Network: The facilities, providers and suppliers your health insurer or plan has contracted with to provide health care services. Networks change, so it’s important to check with your health plan to be sure your provider(s) are in-network at the time you receive care.

      • In-Network: Provider or facility has a contract with the insurance company and has negotiated a contracted or discounted rate with the insurance. You generally pay less when you receive care from an in-network provider.
      • Out-of-Network: The provider or facility does not have a contract with the insurance company. You generally pay more when you receive care from an out-of-network provider.

      Non-Covered Benefits or Exclusions: Health care services that your health insurance or plan doesn’t pay for or cover.

      • Common exclusions: Travel vaccines and services, massage therapy, cosmetic procedures, non-medically necessary services or supplies, etc.

      Medically Necessary: Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

      Out-of-pocket maximum: The most you will pay for covered medical expenses during the plan year. Once the out-of-pocket limit has been met, the plan will pay 100% of covered charges for the rest of that plan year. This limit never includes your premium, balance-billed charges or health care your health insurance or plan does not cover.

      Preauthorization or Prior Authorization (PA): A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health insurance or plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost. Note: Prior authorization is not required during medical emergencies.

      Preferred Provider Organization (PPO): A type of health plan that contracts with medical providers, such as hospitals and doctors, to create a network of participating providers. You pay less if you use providers that belong to the plan’s network. You can use doctors, hospitals, and providers outside of the network for an additional cost.

      Premium: The amount you pay for your health insurance coverage. When shopping for a plan, keep in mind that the plan with the lowest monthly premium may not be the best match for you. If you need much health care, a plan with a slightly higher premium but a lower deductible may save you a lot of money.

      Referral: A written order from your primary care doctor for you to see a specialist or get certain medical services. In many Health Maintenance Organizations (HMOs), you need to get a referral before you can get medical care from anyone except your primary care doctor. If you don’t get a referral first, the plan may not pay for the services.

      Subscriber: The name of the policy holder of the insurance plan. In a family plan, this is typically a parent.

      Videos to watch:

      https://youtu.be/xs7MNNqdN-o

      Legal Fees and Documentation

      Please be advised that should a Daya medication provider or clinician be requested to write a letter on any court matter, it will NOT be stipulating in writing or in person as to an opinion. As your provider(s), Daya providers may only provide documentation of attendance as a client and/or drug screen results. At no time will Daya providers make a recommendation with regard to custody or any other court related matter. If a court order is served and is requesting that a Daya providers(s) be present in person and/or there is a request for records, we will request your consent before turning over confidential information. As your provider, Daya will discuss with you exactly what has been requested by court and there is no guarantee that the information can be kept confidential. This information includes mental health history, current status, prescribed medication and may not be in your best interest. The provider-client relationship does not render Daya provider as your advocate. Daya provider(s) will withhold any opportunity to engage in a dual relationship in this way. Should any Daya provider be ordered by court and/or requested by clients lawyer to prepare documentation or consult with a clients lawyers, the follow fees will apply:

      • $450 per hour plus travel to and from the court and any accommodations as needed.
      • $350 per hour for preparation, such as documentation or consult time and will be billed in increments of 15 minutes.
      • Daya providers will not be on-call at any time for court/legal related matters. Should a case be tried, Daya providers will be paid in full per hour per day as it hingers our ability to be available to other clients


      ACKNOWLEDGEMENT OF POLICIES AND PROCEDURES AND CONSENT FOR TREATMENT

      As a healthcare provider, we are required to make you aware of Daya Mental Health and Wellness policies and procedures. By signing below, you consent to agreement of your rights as a patient and understand that these rights may be limited by certain legal policies implemented to protect your safety, you also understand and agree to all the specified clinic rules and procedures and acknowledge that failure to follow such guidelines on your behalf as a patient may result in termination of your treatment.

      Daya Mental Mental Health and Wellness policies may be subject to change, of which you will be informed at your next clinic visit.

      I grant permission for the providers at Daya Mental Health and Wellness to perform such examinations, medical, and therapeutic procedures as may be professionally deemed necessary or advisable and to communicate about them via telephone, mail, facsimile, and e-mail for my/the patient's diagnosis, treatment, payment, and healthcare operations.

      I am aware that healthcare is not an exact science and that no guarantees or promises have been made to me as to the result of treatment or examination. I understand that there are inherent risks in pharmacologic treatment and that there may be adverse side effects and results that are not anticipated. Hereby, I consent to be treated with knowledge of possible risks and understand that I will be informed of possible adverse effects when applicable.

      I understand and agree to the policies and procedures of Daya Mental Health and Wellness and consent for treatment:

      DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.


      Payment Authorization Form

      We are committed to meeting your healthcare needs and keeping your insurance and other financial arrangements as simple as possible. In order to accomplish this in a cost-effective manner for all our patients, we ask that you adhere to our practice’s financial policy. By signing below, you are agreeing to its terms

      1. I am ultimately responsible for payment of charges for services I receive from this practice including those covered by my insurance. As a convenience, this practice will submit claims for reimbursement with my insurance provider; however, all payment responsibility is ultimately mine.
      2. Some immediate payment may be expected at the time of service. This may include a co-pay and additional payment if this practice determines that the cost of my visit today will not be reimbursed by my insurance provider. This often happens if my deductible is not yet satisfied.
      3. This practice may deny service or charge a service fee for failure to pay a co-pay at the time of service.
      4. It is my responsibility to provide my current address, telephone number, email address, and insurance information at each visit.
      5. I agree to provide the above practice and/or its designated payment agent with my debit/credit card.
      6. I understand that my signature and payment information will be maintained on file digitally for future use by the practice. Card or ACH Information will be obtained through a card swipe, manual entry from the card or orally in person or over the phone.
      7. If warranted, this practice may offer the option of paying my share of costs via an automated payment plan. I understand that I may incur some interest expense beyond my balance in exchange for this convenience. I can avoid interest charges by paying my bill immediately if required or by its due date.
      8. I authorize the above practice and/or its designated payment agent to apply charges to my payment card and/or ACH account for all amounts owed to the practice for medical visits, procedures or supplies, including (i) amounts agreed as part of a payment plan, (ii) copayments, (iii) coinsurance (after application of insurance proceeds), (iv) amounts not covered by insurance and/or (v) fees (if applicable) charged by the practice for failure to keep a scheduled appointment or provide timely notice of appointment cancellation.
      9. All unpaid balances will be sent to collections after the balance reaches 60 days past due and no attempt has been made by client to make payment. If arrangements are not made to pay past due balances, clients will be discharged from the practice with referrals to other providers. Upon turning over balance to collection agency, a fee of 50% of total balance owed will be added to bill for collection and administrative charges. All charges for disputed charges from client will also be added to clients bill balance for collections.
      10. Transaction receipts will be maintained in the patient file or will be emailed to me if I provide and maintain a valid email address.
      11. I authorize the above practice and/or its designated provider to send electronic account statements and invoices to my email address on file. I understand that it is my responsibility to maintain a current email address on file and that I will not receive a mailed copy of any electronic statement.

      This authorization will remain in effect until I provide written notice of cancellation to the practice. Authorization for services already rendered cannot be cancelled or refunded. I agree to notify the practice in writing of any changes in my payment or other information.

      AGREEMENT TO PAY FOR SERVICES

      I agree to pay for the services rendered by Daya Mental Health and Wellness, PLLC, as indicated below.
      Payments will be made by credit/ debit card and billed by our biller the week after your appointment. The card which I authorize you to use:

      **Changes to the Credit Card or Checking information should be reported to the office IMMEDIATELY**

      **It is understood that if the patient misses payments, without prior notification and agreement, the practice reserves the right to transfer BALANCE to a collection agency.**

      3 digit code on back of card (Amex is 4 digit on front)
      DISCLAIMER: By typing your name above, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

      Your information will be encrypted.

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