George Jackson, MD

Please correct the errors described below.

George Jackson, MD PROCESS OF TREATMENT: Treatment goals will be discussed with you based on your concerns and problems. It is important to understand that the process of psychotherapy can be uncomfortable at times before your goals are reached. Successful therapy is the result of a joint effort and a good working alliance with your physician. For certain conditions, medication can be helpful in treatment and this will be discussed in your session. *Please keep track of the number of pills you have remaining and call one week prior to running out to avoid the possibility of missed medication. * APPOINTMENTS: All session are arranged by appointment only. This office does not give reminder calls for appointments. It is your responsibility to remember and keep track of your appointments. CANCELLATIONS: You must give at least 24 hours advance notice to cancel your appointment. If no notification is given, you will be charged $75 for a missed appointment. Please be aware that most insurance companies will not reimburse for missed sessions, making you responsible for the entire fee. PHONE CALLS AND EMERGENCIES: Calls to the office are answered by our receptionist or our 24- hour answering service. Most calls requiring a response will be made by myself within 24 hours. If a situation requires an immediate response, call 911 or go to the nearest hospital emergency department. A fee may be charged for telephone consultation in special situations. BILLING AND PAYMENTS: You are expected to pay for each session at the time it is held, unless we have agreed otherwise or unless you have insurance coverage. If you have insurance coverage you are expected to pay your co-pay at the time of each appointment. The co-pay for mental health is often different from that for other medical visits. If you are uncertain about your co-pay, I encourage you to contact your insurer. Until you know for certain what your co-pay is, I would ask that you pay 20% of my fee at the time of each appointment. Ultimately, you are responsible for your account and are expected to pay your bill, whether insurance pays for a portion or not. A finance charge of 1% per month may be added to any balance not paid within 60 days after the charge is incurred. If 90 days pass without a payment, accounts may be sent for collections. any collection , legal fees or costs necessary to collect unpaid balances will be your responsibility. If you have any questions about your account, please ask to speak to our bookkeeper. PLEASE UNDERSTAND I DO NOT PERFORM EVALUATIONS OR ASSESSMENTS FOR LEGAL PURPOSES, SOCIAL SECURITY DISABILITY OR PSYCHOLOGICAL REPORTS. INSURANCE: I am a contracted provider for many, but not all, local insurance companies. You should be sure to check with your insurer and my intake office to learn whether I am a provider for your plan. You should also learn whether you need a referral or preauthorization in order to be eligible for your mental health benefit, whether you have a separate annual deductible for mental health, and whether your mental health benefit has a maximum yearly number of visits or a maximum yearly dollar amount. My billing office will submit claims to insurance companies that I am contracted with. In order for this to occur you must complete the insurance portion of the “Patient Information” form that was given to you with this policy, you also need to provide a copy of your insurance card. CHANGES TO THIS OFFICE POLICY: From time to time I may change the business polices described in this document, I will attempt to inform you of relevant changes. INFORMED CONSENT: Your signature below indicates that you have read the information in this document and agree to abide by its terms during our professional relationship.

* I acknowledge I have read the financial policy above and that I am responsible for all charges regardless of any insurance coverage I have. I understand that delinquent accounts may be assigned to a credit reporting collection agency and agree to pay for all legal costs and expenses including reasonable attorney fees. By signing this Acknowledgement, I agree that my electronic signature is the legally binding equivalent to my handwritten signature. Whenever I execute an electronic signature, it has the same validity and meaning as my handwritten signature. I will not, at any time in the future, repudiate the meaning of my electronic signature or claim that my electronic signature is not legally binding.

Your message will be encrypted and can only be read by George Jackson, MD.