Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA

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1 Columbia Associates in Psychiatry 2501 N. Glebe Rd Suite 303 Arlington, VA Welcome to Columbia Associates in Psychiatry! Thank you for choosing us to take care of your behavioral health needs. Please fill out the following forms and bring them with you to your appointment. Since we are a Fee for Service practice you do not need to fill out the health insurance information section, but please note that we will provide you with the forms you need to file to your insurance company for any possible out of network benefits that you may qualify for. We look forward to working with you. Respectfully, The Columbia Associates Team

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4 Columbia Associates in Psychiatry Please read carefully the office procedures. If any questions arise please do not hesitate to ask for clarification. FEES: (*otherwise specified) M.D (Psychiatrist): Initial Visit Charge: Therapy and Medication Management Charge: Medication Management Charge Phone Visit $ for minutes $ for minutes $ for minutes $ 175 for 30 minutes TMS Initial Evaluation $ 350 TMS Mapping $ 400 TMS Mapping and Treatment $ 600 TMS Daily Treatment $ 400 PH.D (Psychologist): Initial Visit Charge: Individual Therapy: Psychological Testing Collateral Therapy Family Therapy LSW (License Social Worker): Initial Visit Charge: Follow up Sessions Family Therapy Medical Records Charges: $ for minutes $ for minutes $ per hour $ 190 per session $ 190 per session $ for minutes $ for minutes $ 170 per session $10.00 for 0-15 pages $ for pages $ for 50 pages and up Appointments: Appointments cancelled within 48 hours, will be charged the full fee of the visit. (This applies to all sessions.) However, the patient will not be charged if a serious emergency or unexpected illness occurs prior to the set appointment session. Telephone Calls and Other Services: There is no charge for brief calls to make appointments or clarify administrative issues. However, we do ask that the patient gives our office at least a 48 hour notice for any refills/ prescription request. There will be an appropriate charge for any calls to the doctor or therapist that deal with significant clinical issues at the appropriate fee. In addition, there will also be a charge for report preparation and/or medical records request at the appropriate fee above. We do not participate with insurance; therefore we will provide the patient with the necessary paperwork to submit to their insurance company for reimbursement. The patient will be responsible for all services (unless otherwise specified): which includes, payment for appointments, late cancellations, missed appointments, telephone sessions, transcription for records of preparation of a report, and any other type of services we provide. Please fill out the following Easy Pay Consent Form attached I have read and understand all Signature: Date:

5 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED, DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Health Insurance Portability & Accountability Act 1996 ( HIPPA ) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPPA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include a physical examination. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment. Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Office: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations. The right to inspect and copy your protected health information.

6 The right to amend your protected health information. The right to receive and accounting of disclosures of protected health information. The right to obtain a paper copy of this notice from us upon request. We are required by law to maintain the privacy of your protected health information and to provide with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filling a complaint. Please contact us for more information: For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C Toll Free

7 Columbia Associates in Psychiatry (703) N Glebe Rd # 303 Arlington, VA Copyright 2008 Privacy Policy PATIENT EASY PAY CONSENT FOR ARLINGTON Please complete and return this form to our office if you would like for us to bill your Visa or MasterCard automatically for any balance owing on your account at the time of service and/or past due. Today s Date: / / Patient Name: (Print) Parent/Guardian Name: (Minor patient) (Print) I authorize Columbia Associates in Psychiatry to charge my Visa or MasterCard credit card for any out of pocket expense which may be my responsibility until paid in full. I understand that if the charge is not accepted by the credit card company, I will immediately make payment to the practice. I understand that I may cancel this authorization through written notice to the practice named above at any time, but by doing so I acknowledge that the balance owing will be due and payable in full. Responsible Party Signature: Relationship, if not patient: Today s Date: / / We accept Visa or MasterCard Cardholder Name: Cardholder Mailing Address: City: State: Zip Code: Credit Card Company Name: Amount$ Account Number: Expiration Date: / Security code: (Three digits on back of the card) Cardholder Signature: