I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers
  • Conduct normal healthcare operations such as quality assessment and physician certifications

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I can request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my requested restrictions, but, if you do agree, you are then bound to abide by such restrictions.

Office and Financial Policies

We would like to thank you for choosing Blue Mountain Psychiatry as your medical provider, as one of our patients we would like to keep you informed of our current office and financial policies. We require that you read and sign this document prior to any treatment, please keep this document for future reference.

Canceled Appointments: If you are unable to keep your scheduled appointment, please call our office within 24 Hours to reschedule. This will allow us to provide that time slot to another patient, otherwise you will be charging a $40.00 fee add to your account this will not be covered by insurance company.

No Insurance: Payment will be due at the time of service, if you are unable to pay your balance in full you will need to make prior arrangements with our customer service Representative or Financial Coordinator.

Insurance: please bring your insurance card with you at the time of your appointment, with insurance plans where we have agreed to participate in the network as a provider, your carrier requires that all Co-pays be paid prior to any services bring rendered

You are responsible for any Co-insurance, Deductibles or non-Covered services not paid by your insurance, you will receive a statement from our office indicating what your insurance has paid, any balance remaining is due upon receipt

Payment Refund: No return allowed on any service except the following cases

  1. if any patient pays advance payment then cancel his/her appointment within 24 hours we refund full amount but id he/she does not come to the appointment we will deduct $40.00 fee and refund the rest amount
  2. If any patient pays Co-pays, then the insurance company cover full amount

For Credit card payment we refund to the same credit card for cash payment they have to wait one week to prepare check.