All patients must present a valid, non-expired state-issued Driver’s License, State issued ID card, passport, or
Passport ID card.
Appts should be canceled at least 24 hours in advance. If not, there will be a $50 no-show/early cancellation fee that will have to be paid before rescheduling.
Renewed Foundations Mental Health Services takes patient privacy seriously. As a part of our new patient paperwork, a full HIPAA- Patient privacy notice will be provided and each patient will acknowledge via signature their review and understanding of the policy.
Our office will provide refills and renew prescriptions only during appointments. This will reduce errors, improves patient safety, and ensures appropriate follow-up.
Paperwork or Letters:
There is a fee for paperwork and letters that need to be completed by the provider. FMLA or Disability paperwork will not be completed at the first visit. You will need to be patient of RFMHS for at least 6 months.
Controlled Substance Policy
Renewed Foundations Mental Health Services will provide controlled substances for patients when it is found to be necessary for the management of their diagnosis. All patients (parents/guardians) will be required to sign a controlled substance contract.
- Patients may be called in for an unannounced drug screen or pill account at any time during their treatment.
The patient must appear by 5 PM on the day they are notified. Failure to appear may result in discharge from being prescribed controlled substances.
Patients will be asked to limit pharmacies to no more than TWO.
- Patients are required to complete a drug screen prior to receiving any controlled substance and at ANY time during their treatment.
- If the drug screen is positive for any illicit substances (i.e. meth, cocaine) or for medications that are not preschbed for the patient, the patient will be discharged from the use of controlled substances. If the patient is thought to be in danger of withdrawal, a 30 day supply will be provided for the patient. The patient will then be responsible for finding another provider who will prescribe controlled substances. The patient may continue to be a patient with RFMHS for non-controlled medications.
- If a drug screen is negative for medication that should be in the patient’s system, the patient will be discharged from being prescribed controlled substances.
Patient Dismissal Policy
It is your right to terminate treatment or your relationship with us for any reason. We reserve the right to terminate the patient relationship at our discretion, via a non-voluntary discharge letter if any of the following occur:
- The Patient exhibits physical violence, physical or emotional intimidation, verbal abuse of any kind, and/or the Patient or a Patient’s family member(s) carry weapons or engage in illegal acts of any kind on the Provider’s premises or during treatment.
- The Patient or a Patient’s family member(s) engage in abusive phone or email correspondence. The Patient refuses to comply with stipulated clinic rules, refuses to comply with treatment plans/recommendations, and/or does not make a payment in a timely manner.
- The Patient repeatedly cancels, late cancels, or no shows for appointments (3 times).
- Other cause deemed reasonable by the Provider in their sole discretion.
**Termination of the relationship by either party does not relieve the Patient or his/her responsible parties of any outstanding fees due.***
Financial Agreement Insurance Information
Patients are responsible to make sure they have active insurance coverage, they have coverage for mental health (outpatient/medication management services),and that RFMHS is IN-Network with your insurance plan. Any co-payment, coinsurance, or deductible we charge is based on the benefits provided by your insurance company(s). As a courtesy, we will verify your insurance benefits before your initial visit but you are solely responsible for this. Patients are responsible for any outstanding balance if the insurance carrier denies benefits, changes co-payment, alters your deductible, retracts a payment, or does not provide benefits as estimated. Patients or the Responsible Party must pay the balance regardless of the reason the insurance company denies coverage. Patients will be responsible for requesting reimbursement from their insurance company if necessary.
· Psychiatric Evaluation: $250
· Medication Management Follow Up: $125.00
· Medical Marijuana Evaluation $250
Services offered that incur additional charges are based upon time spent to complete the service including, but are not limited to:
· Letters (1-3 pages): $25.00-$50.00
· FMLA / Disability Paperwork: $50.00-$75.00
· Copying: $0.10 per page.
· Records $25.00 up to 50 pages, then 0.10 per page
*Payment for additional charges is due upon request of the service.