Patient Financial Responsibility
Policies and Procedures

DMD Endeavors LLC, d.b.a. Philadelphia Integrative Psychiatry (the “Practice”, “we”, “us” or “our”) is dedicated to providing you with quality patient care and is also aware that financial concerns are important to you. This Patient Financial Responsibility Policy is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs. By signing below, you acknowledge and agree to the following:

APPOINTMENT POLICIES AND PROCEDURES

Late Cancellation Fee:  We are happy to accommodate you and your behavioral health needs and reserve a time in your provider’s schedule just for you.  However, in consideration of others, we have established the following cancellation policies.  We understand that there are circumstances that may prevent you from keeping your appointment, but once a patient has been given a time slot, canceling on short notice does not give us adequate time to schedule another patient in need of treatment.  We price our appointment slots as if all patients keep their appointments.  Thus, it would be unfair to other patients if they were charged a higher rate to make up for those who do not show up.  Similarly, practitioners at the Practice only get reimbursed when the patients keep their appointments.  Accordingly, please review the following policies carefully.  The main message is that you must cancel at least 48 business hours in advance to avoid a late cancellation fee:

• Business days are Monday through Friday.  Business hours are currently until 5 pm, but are subject to change.  Canceling an appointment after 5:00 p.m. on any business day (via electronic message, voicemail, or text message) is equivalent to canceling at 8:00 a.m. the following business day.  For example, if you are a new patient with an appointment scheduled for a Monday at 3:30 p.m. and you cancel the appointment  any time from 3:31 p.m. on the preceding Thursday to 3:30 p.m. until the day and time of the appointment, there will be a full late cancellation fee, typically the full cost of the appointment, or the loss of the deposit for new evaluations. 

• There will be no charge to any patient for canceling an appointment 2 business days (48 business hours) or more before the appointment.

Please understand that this policy is not meant to be punitive and, of course, we try to work with patients in extreme circumstances; we give one exception per year for medical illnesses or true emergencies in the family.  The fees discussed above will be automatically charged to the credit card on file.  Please note that charges for late cancellations or missed appointments are not eligible for insurance reimbursement.

We will also attempt to contact you using your preferred method of contact in order to reschedule the appointment.  You will be required to remit payment in full of any outstanding late cancellation fees before we will reschedule your appointment.  If we are unable to make contact with you for more than two weeks after a cancellation, the Practice reserves the right to terminate the treatment relationship.  Please see the termination section in the clinical disclosures form provided.

PAYMENT POLICIES AND PROCEDURES

Payment and Fees:  We accept payments via credit or debit card through a secure service called Square Payments (https://squareup.com/).  Square Payments will securely store your credit or debit card information in their system.

• For new clients seeing the physician, we require a downpayment in advance of $500 to secure the appointment, paid through a link to Square Payments we will send you (the downpayment for evaluations with the Nurse Practitioners is $300) or charged by our intake team using the card on file.  This is refundable for clients that cancel in accordance with our cancellation policies (see above for more on that).

• For follow up appointments, billing will occur automatically through the credit card saved in the Square Payments or our Electronic Health Record.  You can change your preferred card by contacting us at least 2 business days in advance of your appointment.  If you notify us later than 2 business days, we cannot guarantee that the credit card on file will be changed in time for the next appointment payment.

We also accept cash in person (although we still require a deposit via CC that can later be refunded if cash is preferred).  In addition to other fees discussed in this document, the Practice will charge a $35 administrative fee for any credit card chargebacks or disputes, in addition to the charges originally invoiced.

• Charges for this practice will typically appear on your statement as: 

  • SQ*PHILA INT PSY

Session Charges:  Session fees cover the cost of the visit and paperwork associated with completing the visit.  We will complete two occasions of filling out brief forms (five or fewer minutes) or brief phone calls (ten or fewer minutes) at no charge.  The Practice will charge for any additional occasions and any time beyond those limits at the same rate as our twenty-five-minute follow-up appointment, in five-minute increments.

Between Session Charges: Future correspondence conducted with or on behalf of a patient—whether via phone, text, email, app, or virtual video—will be charged at your provider’s rate for a twenty-five-minute follow-up appointment, billed in five-minute increments. Details on this rate can be found under "Medication Follow Up Appointments with our Psychiatrists" or “Services with A Psychiatric Nurse Practitioner” on the Philadelphia Integrative Psychiatry pricing page (https://phillyintegrative.com/pricing).

Balances and Collections:  Balances that remain unpaid for more than thirty days will incur a 10% fee, applied monthly. If a balance remains unpaid for over ninety days, it may be referred to a collection agency or law firm for collection efforts. In such cases, you agree to reimburse the Practice for any costs incurred in obtaining payment for services, including legal, administrative, or clinical expenses, in addition to all other amounts owed.

Insurance:  While some of our providers may be partnered with Headway to accept certain insurances for certain services, The Practice itself does not accept insurance and does not accept insurance payment assignment.  This means that all charges submitted to you by the Practice must be paid by you directly to the Practice.  This excludes third party payers, including Headway, who pays the practice/contractor directly.  The Practice believes that arranging its payment system in this manner provides many advantages not only to the Practice, but also to the patient.  For example, the Practice is not restricted by any limitations that insurance companies often place on practices with regard to the length of sessions or the number of sessions per day.  This allows our practitioners the flexibility to spend more time with you.  If you would like to submit your charges to your insurance provider for reimbursement, the Practice will provide to you a detailed billing and payment statement that you may submit to your insurer.  NOTE:  THE BILLING AND PAYMENT STATEMENT WILL INCLUDE INFORMATION NECESSARY FOR REIMBURSEMENT, INCLUDING THE RELEVANT BILLING CODE(S) AND DIAGNOSIS/DIAGNOSES.  The Practice will not negotiate with your insurer or otherwise advocate on your behalf for reimbursement, but the Practice will reasonably cooperate with you in your efforts to obtain reimbursement.  Whether a charge is reimbursed and the amount of any such reimbursement is determined by your agreement with your insurer.

Laboratory and Genomind Studies:  At times the Practice will need to order laboratory studies.  Please be aware that the cost of labs is not included in the Patient’s visit charge and is your responsibility.  Please be sure to check with your insurance carrier prior to getting labs to learn what percentage of the lab fees is covered.  This varies by insurance company.  The practitioners at the Practice have no financial affiliation with any laboratories or genetic testing companies.  We often recommend these services but we are not responsible for any costs passed on to the patient.

Court appearances / legal letters of medical opinions:  If a subpoena or request necessitates action, the patient will be responsible for payment of applicable fees. For the Practice’s psychiatrists, such fees include a $600 hourly fee for preparation, travel, and appearance. For the Nurse Practitioners, the hourly rate for preparation, travel, and appearance will be $400. Fees also include costs of copying medical records, as permitted under applicable state or federal laws and regulations, clerical and administrative work, and all legal fees incurred by the Practice for consultation regarding legal requirements and for the purpose of complying with the subpoena or record request.

Property Damage: Clients who cause damage to physical property are responsible for the costs associated with replacement or repair. 

• In the case of damaged furniture, clients must pay for a new item of equal quality at current market prices. 

• For items that cannot be directly replaced, such as paint, walls, various components of the building itself, or the building exterior, clients are responsible for the costs of repair or replacement, including any related administrative and permit fees. All repairs or replacements must comply with township specifications, regardless of the item's condition before the damage occurred.

STATEMENT OF FINANCIAL RESPONSIBILITY:  I understand that as the patient or responsible party (if applicable), I am personally responsible for the payment of treatment and care provided to me by the Practice whether or not:  I have insurance; my insurer covers the Practice’s charges; the Practice and/or I proceed with treatment; or my treatment with the Practice is successful, for which I understand there is not any guarantee. I am fully and personally responsible for the payment of all charges, fees, and expenses charged by the Practice.

I HAVE READ AND I ACCEPT THE TERMS AND CONDITIONS OF THESE PATIENT FINANCIAL RESPONSIBILITY POLICIES AND PROCEDURES.

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