*Please send a copy of the insurance Card(front and Back). It is required to verify insurance*
No Show and Cancellation Policy
$25 NO SHOW / Cancellation Fee
is the sole responsibility of the patient
As a client of synergy physiatric Mental Health, I recognize my responsibility to:
1. Participate in the treatment program and therapeutic activities in the
Treatment Plan I sign.
2. Not engage in assaultive or destructive threats or behavior towards
Our staff, visitors, property, or other clients. I
understand that such treatments or behaviors may constitute grounds
for dismissal from treatment and/or possible criminal prosecution
and/or civil suit.
Patients who schedule clinic appointments and fail to keep them have a
negative impact on patient care and productivity. The No Show process is
designed to minimize disruptions in the scheduling process and disruptions in
delivery of care. The No Show process is ultimately intended to improve both
the health and quality of life of our patients by increasing access to care.
NO SHOW and appointments canceled with less than 24 hours notice are
subject to a $25.00 cancellation fee.
Patients who do not show up for their appointment will be considered a NO
SHOW.
Cancellation Fees and NO SHOW Fees are the SOLE RESPONSIBILITY of the
patient and must be paid in full before the patient's next appointment.
Our practice firmly believes that good physician/patient relationship is based
upon under____
Consent For Communications
By signing this form, I authorize Synergy Psychiatric Mental Health to send automated text
messages to my cell phone, leave voicemail, and/or send email. We use this information strictly
for the purposes of communicating with you more efficiently. We do not sell share or rent our
users' personally identifiable information unless required by law to do so, and we do not send
email or other communications without your permission. We never send spam. Please
communicate with me by:
Informed Consent for Medication Administration
Certain medicines used in psychiatry have been assigned what are called “black box warnings”
by the FDA. This refers to adverse effects that it is very important for prescribers and patients
to consider in their treatment decisions before starting these medications. Some of these
warnings are as follows:
1. Some medications commonly known as antipsychotics are prescribed for many
conditions, including mood and anxiety disorders, in addition to their roles as
antipsychotic medications. These medications may cause involuntary muscle symptoms
such as tics, tremors, spasms, and these adverse effects may rarely become
permanent, a condition called tardive dyskinesia. If you are prescribed one of these
medicines, we will review this issue in great detail, and answer any and all questions you
may have. If we agree that the prescription is medically necessary, we will monitor
closely for any of these unexpected and unpleasant effects.
2. Some medications are associated with higher risks for weight gain and metabolic
disturbances, such as elevated glucose or triglycerides, or a worsening of diabetic
control. These include some antipsychotics, anticonvulsants, and antidepressant
medications. If you are prescribed one of these medicines, we will review this issue in
great detail, and answer any and all questions you may have. If we agree that the
prescription is medically necessary, we will monitor closely for any of these unexpected
and unpleasant effects.
3. Antidepressants have been assigned a black box warning about the unexpected
appearance of new suicidal ideation. This is very uncommon, and these medicines are
clearly demonstrated to improve psychiatric health and reduce suicidal ideation in the
great majority of cases. There are some factors that may indicate that your risk for this
is higher than usual, and we will investigate these with you.
4. Unless you are experiencing an absolutely intolerable adverse effect of a brain-acting
medication, please do not stop it abruptly. All centrally-acting medications including
antidepressants and anticonvulsants carry a risk of an unexpected discontinuation
syndrome. Contact us to discuss your.
At Synergy Psychiatric Mental Health, we understand that situations arise in which a leave of
absence from work is necessary for your health or the health of a family member. For extended
time away from work, disability papers are sometimes needed. It is our policy that the following
conditions be met in order for us to consider completing these forms for you:
1. We only complete these forms for patients who have been in regular treatment with us
for at least 6 months. This ensures that we know the person and their situation and
illness well.
2. Completing these forms requires time outside of clinic hours, so we have to charge a fee
of ______ for each occurrence. This fee is your responsibility and is not covered by
insurance. It must be paid in advance.
3. These policies also apply to letters on your behalf.
4. Any questions about specific fess should be directed to our front desk and office
manager.
Did you mean $425? Maybe consider a schedule of fees: (1) simple letters, (2) FMLA, and (3)
disability papers in order of complexity. I charged $50 for letters, $100 for FMLA, and $200 for
disability forms, based on the time it took to do the task.
