Thank you for your interest in Pure Psychiatry and ACPC! We're excited for you to start this journey. Please make sure that you have plenty of time available to complete this form. No information will be submitted until you've fully completed.

You will get a confirmation email once submitted.

You will need your Picture ID and Insurance Card.

This form should be filled out by either the patient or someone who has the legal right to sign for them (Parent of minor, Legal Guardian or Medical Power of Attorney).

Disclaimer and Financial Agreement

The practitioners at Pure Psychiatry Group and Adrian Counseling and Psychiatric Clinic are independent of each other in their practice and professional services. Any claims, whether implied or expressed, will only be addressed between the patient and their individual provider (counselor, nurse practitioner, physician assistant, or psychiatrist).

I consent to full responsibility for payment of services received and agree to pay in full at the time of service, unless other arrangements have been made with my insurance or provider.

I understand and agree that I am responsible for the full cost of any missed appointment when no cancellation notice is given at least 24 hours in advance. I also agree to pay a $50 collection fee if action is necessary to recover unpaid balances on my account.

Acknowledgment of Recording Policy and Confidentiality Rights

I understand that all information shared during mental health treatment is confidential. I have been informed that audio or video recording of any therapy or psychiatric session is strictly prohibited unless there is mutual written consent from both the provider or agency and the patient, regardless of the patient’s age. Unauthorized recording is not permitted under any circumstances. I also understand that any recording made without proper consent is considered unlawful and will not be used in any legal, clinical, or administrative matter; such recordings will be excluded and treated as invalid. By signing below, I acknowledge and agree to these conditions and understand my rights and responsibilities.  Michigan law (MCL 330.1748) Ohio Revised Code section 5122.31

I agree to indemnify Pure Psychiatry Group and ACPC, PLLC, from any legal action as of the date signed below.

• I authorize use of this form on all my insurance submissions.
• I authorize release of Information to all my insurance companies.
• I understand that I am responsible for my bill (cash pay, deductible and/or copay included).
• I authorize billing for late fees and cancellation fees.
• I authorize billing for Tele-health/Tele-psychiatry visits.
• I authorize my health care provider to act as my agent in obtaining payment from my insurance company.
• I consent to full medical treatment, telehealth and in-person services. I agree that failure to maintain insurance or cover patient balances will result in cancellation of appointment and medication management discontinuation including omission of refills of medications.
• I authorize direct payment to my health care provider.
• I permit a copy of this authorization to be used in place of the original.

Signature below is acknowledging the receipt of: HIPAA Notice, Non-Discrimination Policy Agreement & Controlled Substance Agreements above.

It is your responsibility to know your individual insurance policy. Many insurance policies have exclusions. Most have deductibles, co-payments and co-insurances. Some insurance policies may not cover our services/including tele-medicine.

It is important for you to check with your insurance carrier to determine if the provider you are seeing is listed as an "in-network" provider. If they are not listed as an "in-network" provider you may have a higher deductible and/or co-pay.

Regardless of insurance coverage, you are responsible for all bills not covered by your insurance policy. Failure to cover these costs will result in cancelation of appointments including no refills of medications; agreeing that liability of withdrawl of medications is omitted in these situations.

Many of our patients allow family members such as their spouse, parents, or others to call and request medical or billing information. Under the requirements of HIPAA, we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical or billing information released to family members you must sign this form. Signing this form will only give information to family members names indicated below.

I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed. I understand that information disclosed to any authoized recipient is no longer protected by federal or state law and may be subject to redisclosure by the above recipient. You have the right to revoke this consent in writing at any time. 

I authorize Pure Psychiatry Group and/or ACPC to release my medical and/or billing information to the following individual(s):

At Pure Psychiatry Group and ACPC we are committed to providing you with high-quality mental health services. To ensure a smooth and efficient payment process, we have certain financial procedures in place. Please take note of the following information:

We bill usual and customary fees for standard services offered.

Additional services not covered by insurance companies include:

1. FMLA, long term medical leave/extensive forms: $50.00
2. Short medical leave, short-term leave forms: $25.00
3. Late cancel without a 24-hour notice or No-show fee: $50.00
4. Returned check fee: $35.00
5. Medical record copying will be charged according to State Law rates.

I understand payment for services is due at the time the services are rendered. I understand deductibles and co-pays applicable to my policy is best explained by my insurance provider, but is the responsibility of the patient.

Credit Card Information: Pure Psychiatry Group and/or ACPC may require patients to provide credit card information prior to their appointment. This is to ensure that any deductibles determined by your insurance can be covered at the time of your appointment if necessary. Rest assured that your credit card information will be securely stored and processed in compliance with all relevant regulations.
Payment Options: We offer various payment options for your convenience. You have the choice to pay via:

1. Credit Card: Your credit card on file will be charged for any applicable deductibles determined by your insurance at the time of your appointment.
2. Cash: You may pay in cash if that is your preferred method of payment. Please inform the office staff if you intend to pay in cash.
3. Check: If you prefer to pay by check, please let our staff know in advance, and arrangements will be made to accept your payment.
4. Other Digital Payment Methods: We understand that you may have other digital payment preferences. If you wish to use an alternative digital payment method, please notify the office staff in advance so that necessary arrangements can be made.

I understand that Pure Psychiatry Group and ACPC reserves the right to any outside collection agency as a means of collecting any outstanding balances, if my account remains unpaid or payment arrangements are not made. I understand that if my account goes to collections, I will be charged an additional $50.00.

I understand it is my responsibility to keep scheduled appointments or notify the office staff 24 hours prior to the scheduled appointment time or be charged a $50.00 no show fee. This fee is due at the next scheduled appointment and cannot be billed to your insurance carrier.

Fees are subject to change without notice.

For patients not utilizing insurance, usual and customary fees set forth by Pure Psychiatry Group and ACPC apply unless a different rate has otherwise been specified. Furthermore, a good-faith estimate is posted on www.purepsychmi.com and is available at each practice for patients use.

By signing below, I acknowledge that I have read, understand, and agree with the financial conditions described above. I understand that Pure Psychiatry Group or ACPC may require my credit card information and that I have the option to choose my preferred payment method.

Notice: If Patient balance exceeds $200.00 without payment plan/partial payment made, appointments are subject to cancellation by Pure Psychiatry Group/ACPC, including but not limited to voiding of medication refills. Pure Psychiatry Group/ACPC will make a minimum of 3 attempts via text and call to inform patients of options prior to appointment cancellation. Voiding of Medications will include controlled medications and non controlled medications. Patient/Guardian agrees by signing to indemnify Pure Psychiatry Group PLLC & ACPC PLLC of risks of medication management if appointment is canceled due to failure to follow patient balance policy above.

Telepsychiatry is the delivery of psychiatric services using interactive audio and visual electronic systems between a provider and a patient that are not in the same physical location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, electronic scheduling, and distribution of patient education materials.

The potential benefits of telepsychiatry are:

• Reduced wait time to receive psychiatric care.
• Avoiding the need to travel to a psychiatrist; Understanding that this can be subject to change post COVID-19 flexibilities and extensions. Ie. DEA regulations with controlled medications requiring inperson appointment for refills of medications. 

The potential risks of telepsychiatry include, but are not limited to:

• There could be some technical problems (video quality, internet connection) that may affect the telepsychiatry session.

Pure Psychiatry and ACPC utilizes software that meets the recommended standards to protect the privacy and security of the telepsychiatry sessions.

Alternatives to the use of telepsychiatry:

• Traditional face-to-face sessions.

I understand that I have the following rights with respect to telepsychiatry:

1. The laws that protect the confidentiality of my medical information also apply to telepsychiatry. As such, I understand that the information disclosed by me during the course of my treatment is confidential However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding.
2. I understand that the dissemination of any personally identifiable images or information from the telepsychiatry interaction to researchers or other entities shall not occur without my written consent.
3. I understand that there are risks and consequences from telepsychiatry, including, but not limited to, the possibility, despite reasonable efforts on the part of my psychiatrist, that: the transmission of my medical information could be disrupted or distorted by technical failures; the transmission of my medical information could be interrupted by unauthorized persons; and/or the electronic storage of my medical information could be accessed by unauthorized persons.
4. I understand that telepsychiatry based services and care may not be as complete as face-to-face services. I also understand that if my psychiatrist believes I would be better served by another form of psychiatric services (e.g. face-to- face services) will be referred to a psychiatrist who can provide such services in my area. Finally, I understand that there are potential risks and benefits associated with any form of psychiatry.
5. I understand that I have a right to access my medical information and copies of medical records in accordance with State Law.

Patient's Responsibilities:

• I will not record any telepsychiatry sessions without written consent from my provider. I understand that my provider will not record any of our telepsychiatry sessions without my written consent.
• I will inform my provider if any other person can hear or see any part of our session before the session begins. The provider will inform me if any other person can hear or see any part of our session before the session begins.
• I understand that I, not my provider, am responsible for the configuration of any electronic equipment used on my computer that is used for telepsychiatry. I understand that it is my responsibility to ensure the proper functioning of all electronic equipment before my session begins.
• I understand that my psychiatrist determines whether or not the condition being diagnosed and/or treated is appropriate for a telepsychiatry encounter.
• I understand that if the telepsychiatry session does not achieve everything that is needed, then I will be given a choice about what to do next. This could include a follow up face-to-face visit, or a second telepsychiatry visit.
• I understand that post COVID-19 it is my responsibility to contact my insurance company to verify telepsychiatry coverage.

By signing below, I confirm that I have verified my behavioral health benefits with my insurance company and that telehealth is a covered benefit under my insurance plan. If not, I understand that I am responsible for the cost of any telehealth visit not covered by my insurance company.

Patient Consent to The Use of Telepsychiatry:

I hereby consent to engaging in telepsychiatry with Pure Psychiatry Group and/or ACPC as part of my psychiatric evaluation and treatment. I understand that "telepsychiatry" includes the practice of health care delivery, diagnosis, consultation, treatment, transfer of medical data, and education using interactive audio, video, or data communications. I have read and understand the information provided above regarding telepsychiatry.