You have an appointment with one of our doctors.
If you need to cancel this appointment, please give us 3-day notice. Canceling with less notice will subject you to an appointment change fee of $75. This must be paid before a change in this appointment can be made. We schedule 60 minutes for this appointment and last-minute cancellation keeps us from serving others who are waiting to see your doctor.
We kindly ask that you do not cancel this appointment without appropriate notice.
It is very important that you fill out and bring these forms with you. There is a fair amount of information needed and it may take a while to fill out all this information. If you have any other information about past evaluations, please bring a copy for the doctor.
The charge for the initial evaluation is $510. This includes an office charge of $50 which is not billable to your insurance. It is required in addition to your copay if you have one. A credit card on file is required for all new patients.
Please be sure that the physician you are seeing is a provider for your insurance. We do not guarantee coverage if your insurance considers the physician out of network. A credit card is required to guarantee payment and will be needed on your first visit. We are unable to see you without a credit card on file. We also charge an administrative fee of $50 once per year.
For child evaluation, please ask a teacher who knows your child best to fill out the Teacher questionnaire in your packet. The teacher can either give the form back to you or mail it to us directly. If your child is young, please bring a game, toy or books. A caretaker while parents are talking to the doctor may also be appropriate.
Said A. Ibrahimi, M.D.
Please fill out the intake packet before your appointment. Please also bring copies of all past testing, psychiatric or psychological treatment records, school/college records and psychiatric inpatient records/discharge summaries, if applicable.
About the evaluation
There are no standard psychological or laboratory tests by which one can make a psychiatric diagnosis. The diagnosis is made by listening to the presenting concerns, going over the records, looking into family and patient's history, conducting interviews with the patient, the family, and others, if necessary.
The initial evaluation will help you determine
What may be the underlying reason for the problems? Are there any psychological, medical, neurological, or genetic problems underlying the condition? Do the problems present a psychiatric disorder or a variant of normal behavior? What can be done to address the problems and what will happen if we do nothing?
The initial evaluation takes approximately one hour, sometimes longer, and consists of:
The evaluation will give you a good understanding of what's going on. There are many ways to deal with the problems. Many patients and families are uncomfortable about psychiatric medications. We want you to know that medications are not always recommended and often are not even appropriate. The decision about the medication depends on the nature and severity of the problems, the patient's age, associated issues, but ultimately, on the best available treatment option.
If a medication is prescribed, you will be scheduled for follow-up appointments in one week to one month’s time, depending on the problems and the prescribed medication(s).
We look forward to seeing you and hope that we can be of service.
I will be responsible for all bills for this patient, no matter who brings the patient to the office, such as when brought by caretakers, grandparents, stepparents, ex-spouse etc., as long as the services provided are for the benefit of the patient. I understand that if my Insurance plan refuses to cover services given to me by this office, I will be responsible for the charges.
I will provide a current credit card on file. I allow the office to charge fees not covered by the insurance such as for lack of coverage, yearly admin charge, deductibles, unpaid copays, and no-show charges. A statement of such charges will be sent to you.
I agree to pay all bills as presented and all reasonable fees associated at the time with the with collection of such charges including fees for bounced checks, rush Rx, copays, phone consultation charges not covered by insurance, same day cancellation and noshow fees, request for copy of records, school form filling etc. per schedule of fees attached currently in force.
This letter is to inform you of our updated billing practice regarding receiving patient payments. Effective January 2015, we now require a credit or debit card to be on file with our office for full patient payment of services at each appointment.
Why the change? There are several reasons for this change. With the changing environment in healthcare, in particular the Affordable Care Act and High Deductible Health Plans (HDHPs) more responsibility of payment is being placed on the patient. We need to be sure that patient balances are paid in a timely manner. To do this, we need to ensure we have a guarantee of payment on file in our office.
What is a Deductible and How Does It Affect Me? An annual deductible is the dollar amount you must pay out of pocket during the year for medical expenses before your insurance coverage begins to pay. For example, if your policy has a $2,000 deductible, you must pay the first $2,000 of medical expenses before the insurance company begins to pay for any services. This works just like the deductible for your car insurance or homeowner’s insurance policy does.
When do I have to pay for services? Any time you receive medical care, you will be expected to pay in full for your services until your deductible is met. If you have a very large deductible, called a high- deductible insurance plan, you may have to pay out of pocket for most of your primary care services.
How will I know when my deductible has been met? You can call your insurance company at any time to check on how much of your deductible has been met and some insurance companies have this information available online. Every time you receive medical services, you will receive notification from your insurance company with how much they paid or did not pay if the amount went to your deductible when they send you an Explanation of Benefits (EOB.)
How will I know how much you are going to charge me? You will receive a letter in the mail (or e-mail) from your Insurance carrier that explains how much of your office visit they pay and how much you pay. This is called an Explanation of Benefits (EOB.) This letter tells you exactly, according to your health insurance coverage, how much of your health care bill is your responsibility and how much is the responsibility of your insurance to pay.
Then what? We receive the same Explanation of Benefits (EOB) that you do. Most Insurances will send your EOB prior to us receiving our copy. It arrives about 10-20 days after your appointment has been billed. We look at each EOB carefully and determine what your insurance has determined as patient responsibility. This is the same way we normally determine how much to send you a statement for in the mail. All patients with commercial insurance are required to keep a credit or debit card on file. If you do not wish to keep a card on file, we will expect an estimated payment at the time of service. For example, if your commercial insurance requires $190.00 to be paid for standard service and your deductible is not met, you will be expected to pay the $190.00 via check or credit card before you are seen, but this will not include ancillary charges that may arise out of your visit. Once we receive the Explanation of Benefits (EOB) on your visit, we will send a statement if your patient responsibility is higher than the originally collected amount or you will have a credit on your account if your patient responsibility is lower than the originally collected amount. Once we receive the insurance EOB for your visit, we will charge the credit card on file the exact amount as per the EOB that is stated to be patient responsibility. Once charged, we will email you a receipt of payment.
If you have seen other professionals regarding this problem and would like us to co-ordinate with them, please provide us this consent.
For young patients, his or her pediatrician must be added.
I am requesting you to provide all pertinent medical information about the patient listed above to Said A. Ibrahimi, Vortex Psychiatry. This information may be in electronic from such as a PDF file sent via email (email@example.com) Fax or by hard copy mailed to above address.
I am giving my consent to both parties to share and exchange information as appropriate for the care of the patient
If you will be using your medical insurance to pay for visits to this office….
Please read carefully and sign. This is a required form if you want us to bill your insurance.
Controlled substance medications (i.e., benzodiazepines and stimulants) are very useful. However, they have potential for misuse and therefore are controlled by local, state, and federal authorities. Because my provider is prescribing such medications for me, I agree to the following conditions:
I have read this contract and fully understand its content and the consequences of violating this contract. By signing below, I accept the above treatment agreement.
The attached contract is an arbitration agreement. By signing this agreement, we are agreeing that any dispute arising out of the medical services you receive is to be resolved in binding arbitration rather than a suit in court. Lawsuits are something that no one anticipates, and everyone hopes to avoid. We believe that the method of resolving disputes by arbitration is one of the fairest systems for both healthcare providers and their courts. Arbitration agreements between patients and physicians have long been recognized and approved by the State of California. By signing this agreement, yon are changing the place where your claim will be presented. You still can call witnesses and present evidence. Each party selects an arbitrator (party arbitrators), arbitrator. These three arbitrators hear the case. This agreement generally helps to limit the legal costs for both the patients and physicians. This is because the time it takes to conduct an arbitration hearing is far less than for a jury trial. Further, both parties are spared some of the rigors of a trial and the publicity which may accompany judicial proceeding.
Our goal, of course, is to provide medical care in such a way as to avoid any such dispute. We are all caring doctors and do our utmost to be responsive. We know that most problems begin with communication. Therefore, if you have any questions about your care, please ask us.
Evaluation appointment - $475.00
New patients to Vortex Psychiatry – Dr. Ibrahimi
Patients who have not been seen within one year of their last visit.
Medication Management Fee - $150.00
Charged Yearly for the management of medication
Follow up appointments - $225.00
Non- Complex follow up visit 15 – 20 minutes
Follow up appointment - $365.00
Complex follow up visit 30-40 minutes
No call – No show - less than 24 hours’ notice of change or cancellation to appointment
1st occurrence No Fee
2nd occurrence $75.00 fee
3rd occurrence $175.00 fee
after the 3rd occurrence potential discharge of care from Dr. Ibrahimi.
Rush Refill Request - $35.00 per request
1 business day notice via refill request link located on vortexpsychiatry.com – please see refill request rules on our website.
Copy of documents/records - $.25 cents per page
Contact office for details
Letters - $50.00- $150.00
Personal letters, Lawyer letters, schools, psychologist, airlines, accommodations, etc. Contact office for details.
Forms to be completed - $50.00- $150.00
Forms may vary. Contact office for details.
EDD/SDI/SSA - $150.00 per claim
Fee does not include any additional letters per claim fee.
This form completed by:
Child lives with
Biological parents, if different from above
List major psychiatric disorder (depression, anxiety, OCD, schizophrenia, ADHD, alcohol or drug abuse, psychiatric hospitalizations; also include suicide, homicide, and major legal offences) in close members of the family biologically related to the patient.
Information about school
School History (Specify behavioral and academic problems, repeated grade, comments)
Past Medical History
Other Physicians and Therapists currently involved in your care
Medication and Treatment History
Please rate the behaviors:
0 – Never (None)
1 – Sometimes (Mild)
2 – Often/Always (Severe)
(circle the most appropriate number)
Tics are involuntary, rapid, repetitive, purposeless movements or vocalizations
Obsessions are recurrent, unpleasant thoughts Compulsions are behaviors to stop obsessions or other anxious thoughts.
Thank you for taking time to fill this questionnaire for:
Your input is most valuable to us in the assessment of student's learning and social needs. Please return this completed for to the parent(s) or main it back to us at the above address. It will be shared with the family upon request.
What concerns you most about this student?
Your information will be encrypted.