Patient Financial Responsibility Policies and Procedures

BENJAMIN MEDRANO MD, PLLC d.b.a New York 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

  • 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 the NP is $300). 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* NY 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.

Balances and Collections: Balances more than thirty days past due are subject to a 10% monthly fee. Balances more than ninety days past may be submitted to a collection agency or law firm for collection efforts. If we need to send your account out for collection, you hereby agree to reimburse the Practice for the costs of collection, along with all other amounts due and owing by you.

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 the Practice is served with a subpoena or other request seeking or requiring an appearance in court or other proceeding by a member of the Practice’s staff, the patient will be responsible for payment of applicable fees. For the Practice’s psychiatrist, such fees include a $500 hourly fee for preparation, travel, and appearance. 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 the purpose of complying with the subpoena or record request.

Property Damage: In the rare case that a patient destroys or damages any physical property, the patient is responsible for paying in full for a replacement, or repair when replacement is not an option, of those items.

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.