Please read and initial the following statements concerning our office policies:

• I certify that the information I have given on this form is true and correct to the best of my knowledge.
• I understand that if I arrive more than 10 minutes late for an appointment, it is not guaranteed that I will be seen. A $75.00 no show fee will be charged for this appointment if the schedule does not allow for you to be seen.
• I understand that payment is required at the time services are rendered and I assume responsibility for this. I understand there is a $30.00 fee for all returned checks. (Note to divorced parents: Payment is the responsibility of the parent that brings the child into the office for treatment regardless of the divorce decree. The divorce decree is a matter between the divorced parents and the courts and we cannot be placed in the middle.)
• I understand that insurance will only be filed with insurance companies that Thrive Mental Health is contracted with. In order to achieve this, please have all current insurance information on file. I understand that secondary insurance will not be filed.
• I understand that if there are any changes in my insurance coverage, I will notify the business office at least five (5) days prior to my next appointment or the visit will be self-pay or rescheduled.
• I understand that all information obtained in regards to my insurance coverage is not a guarantee of payment by my insurance company. The amount collected at the time of service is only an estimate. I understand that I am ultimately responsible for any and all balances on my account.
• I understand it is my responsibility to keep my appointments. If I am unable to keep my appointments, I will notify the office at least 24 hours in advance. I understand that I will be charged $75.00 for the time reserved if I do not call and cancel or reschedule at least 24 hours prior to my scheduled appointment.
• I understand that regular office hours for Thrive Mental Health Services office hours are Mon – Thursday, 9 am – 5 pm
• I understand it is my responsibility to keep track of my medication supply. I understand that I should request refills during regular office hours and that request received outside regular business hours will not be called into the pharmacist until the next business day. We require two (2) business days’ notice for prescription refills.
• I understand that my records are protected by special laws governing psychiatric/substance abuse records and that I must sign a “Release of Information” form before any records can be released.
• I understand that providers do not appear in court to defend patients / clients, if for any reason there is a subpoena the client will be responsible to pay $1,500.00 for half a day or $3,000.00 for a full day in court. Payment will need to be collected in advance.
• I understand that providers do not do any mental evaluations for court cases.
• I understand the office policy and requirement for scanning/making a copy of patient identification (ID) and insurance card for medication dispensation, billing, and identification purposes. By adhering to this protocol, the office ensures accuracy in patient records, streamline billing processes, and maintain compliance with regulatory requirements.
• I understand that Thrive Mental Health Services has the right to terminate any patients who are non- compliant to office polices / medications. This includes multiple no shows without advance notice (work meetings are not an excused absence), showing up late to appointments on a regular basis, and losing or throwing away medications.

Your calls are welcomed and we will return them promptly during business hours. We do not have an after- hours answering service. You must call the office and leave a voice mail. If you need to make an appointment, please call during our business hours. If you have an emergency, please call 911 or go to the nearest Emergency Room.

I hereby authorize Thrive Mental Health Services. to provide psychiatric services to: me my child