Practice Information, Office Policies, and Consent to Treat

Practice Information, Office Policies, and Consent to Treat

effective 10/01/2012

Jennifer Brock-Garcia provides thorough psychiatric evaluation(s), diagnostic tests, psychotropic medications, if indicated, as well as psychotherapy in treating mental health problems.Jennifer Brock-Garcia’s practice is exclusively an office-based consulting practice. Jennifer Brock-Garcia does not do hospital work or perform emergency medical services. Consequently, Jennifer Brock-Garcia strongly recommends that in addition to her care, that you maintain a relationship with a physician such as with a family physician or internist in order to keep updated with your preventative health care. If the occasion arises when urgent care or emergency services are needed, contact your nearest urgent care or emergency room or call 911, where you can receive care from specialty trained professionals.Jennifer Brock-Garciais not a forensic psychiatric and does not go to court.

NON-PARTICIPATINGor OUT-OF-NETWORK ProviderorNON-COVERED Benefits As Jennifer Brock-Garcia does not participate with any health insurance carriers, you are responsible for paying for all services at the time of service. If insurance coverage is available for the services rendered, a receipt with the required informationis provided, which you can attach to an insurance claim form and mail into your insurance company. Jennifer Brock-Garcia has opted out of Medicare, therefore claimscannot be submitted to Medicare for reimbursement by patients. You are entitled to know the cost of all services and procedures in advance. Please Initial ______

PRESCRIPTIONS | REFILLSIf you are on medication(s) prescribed by Jennifer Brock-Garcia and you need renewals prior to your next follow-up visit, please have your pharmacy contact the office.Jennifer Brock-Garcia will call/fax them back during regular office hours. This will eliminate delays caused by miscommunication between you, our office, or with your pharmacy. Please allow at least 48 hours for this process. New prescriptions and refills for controlled substances cannot be started outside of normal business hours. Please Initial ______

PAYMENT| DISHONORED CHECKSYou are responsible for payment of charges at the time ofservice.Our office accepts cash, personal checks, Discover, Master Card, or Visa. If your check is returned (e.g., refused for insufficient funds), you will be required to pay an additional fee of $35. Please Initial ______

MISSED APPOINTMENTSIt is important that you appear for all scheduled appointments. Your failure to cancel an appointment in a timely manner deprives other patients of an opportunity to visit our office. You will be responsible for paying a missed appointment fee of ½ your missed appointment fee if you fail to appear for a scheduled visit and have not provided at least 24 hours advanced notice of cancellation. This policy is to ensure availability of prompt medical care. Please Initial ______

FEES* * fees are subject to change

Psychiatric Evaluation/Initial Intake: $225

Jennifer Brock-Garcia, PMHNP 4131 Spicewood Springs Rd Ste E4 Austin, Texas 78759

Practice Information, Office Policies, and Consent to Treat

effective 10/01/2012

Medication follow up $100 Please Initial ______

RELEASE OF MEDICAL INFORMATIONAny services orcommunications with Jennifer Brock-Garciais considered confidential; any disclosure of information and/orrecords, related to your care, will only be done by your authorization, request and approval.The only reason this confidentiality may be broken would be if you or someone else was in imminent danger.Please Initial ______

Jennifer Brock-Garcia makes no representations, claims or guarantees that you will be helped with your mental health problems or conditions by undergoing treatment here. However, she will do her best to help you to accomplish your mental health care and wellness goals. Jennifer Brock-Garcia believes that your involvement in your treatment is essential to getting to your goals and sees this relationship as a partnership.

I have executed this consent freely and willingly, and understand itsprovisions. I have read, understand and agree to the above. I recognize that Jennifer Brock-Garcia, PMHNP will rely upon my execution of this document as my consent for treatment.

Signature: ______Date: ______

Jennifer Brock-Garcia, PMHNP 4131 Spicewood Springs Rd Ste E4 Austin, Texas 78759