Brian S. Earthman, M.D., P.A.

Practice Dedicated to Outpatient Adult Psychiatric Care

11901 W. Parmer Lane, Suite 310

Cedar Park, Texas 78613

Office (512) 528-9498

Fax (512) 843-7164

Acknowledgement of Review of

Notice of Privacy Practices & Office Policies

  1. _____I have reviewed and understand this office’s Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I also understand that these documents are available in my patient portal and that I am entitled to receive a copy of these documents if I request one.
  1. _____ Additionally I authorize Dr. Earthman to communicate verbally about my care to the following individuals:

a.______b.______

c.______d.______

  1. _____Assignment and Release: I hereby authorize my insurance benefits be paid directly to Dr. Earthman for contracted services, and I am financially responsible for all non-covered charges. I authorize Dr. Earthman to charge the credit card on file with this office for all non-covered charges at the time they are incurred.
  2. _____If you cancel an initial appointment less than 3 business days before the appointment or do not show up for your appointment, you will be assessed a fee $375 or the contracted insurance rate for your plan. This fee may be reduced to $100 if you schedule and attend a subsequent follow up appointment within two months. If you cancel a follow up appointment less than 3 business days before the appointment or do not show up for your appointment, you will be assessed a fee $25 first time; $100 for subsequent times. This will reset one year after your last late cancellation/no-show).
  3. _____I authorize Dr. Earthman to charge the credit card on file with this office at the time any no-show or cancellation fees are incurred. The only exceptions to this policy are 1) instance of acute medical problems for the patient or person/child the patient has custodial care of or 2) death of immediate family member
  4. _____ Dr. Earthman does not have a 24 hr / 7 day per week practice. He will respond to messages left at his office number as soon as possible. If you are having a life threatening emergency Dr. Earthman would like for you to call911. Other Local psychiatric emergency resources are:
  5. Seton Shoal Creek Hospital (512) 324-2000
  6. Austin Lakes Hospital(512) 544-5253
  7. _____ Dr. Earthman requires that you notify your pharmacy when you need a refill on your medication and have them submit a refill request to Dr. Earthman. Dr. Earthman may not be able to refill your prescriptions before you run out if you give less than 7 days notice.
  8. _____ Dr Earthman requires you to have a Primary Care Provider for non-psychiatric medical care. If you do not currently have a Primary Care Provider you will need to get one within 30 days of your first appointment with Dr. Earthman.
  9. _____ Any medication refill that must be handwritten by Dr. Earthman will be charged a $25 fee at the time the prescription is written unless it is during a face-to-face appointment.
  10. _____ Dr. Earthman charges $75/0.25hr for the time involved in filling out disability, FMLA, and administrative paperwork as well as other duties outside of direct clinical care such as (but not limited to) phone calls. Medical records request from you or any third party with your consent will be billed to you. The fee is per request at a rate of $25 for the first twenty pages and $.50 per page for every copy thereafter. The fees must be paid before the paperwork is released unless it is for emergency medical care.
  11. _____ Dr. Earthman requires that you come for a face-to-face follow up appointment at least every 90 days so he can properly monitor your condition. If you cannot comply with this requirement Dr. Earthman will not refill your medication and will discontinue your care.
  12. _____Prior authorizations for medications are $20. Appeals for medication coverage are $50. To avoid charges please bring a list of your insurance company’s pre-approved medications.
  13. _____If you are a female, heterosexually active, capable of becoming pregnant, and I am prescribing you medications I strongly recommend using a barrier form of contraception and taking 2mg of Folate per day.

By signing below, you acknowledge that you have reviewed these policies and you understand, accept, and will abide by them.

Patient name: ______

Patient signature:______Date:______