Webster Psychiatry & Medicine
Forms & Policies Webster Psychiatry & Medicine, PLLC
1674 Empire Blvd, Suite 300
Webster, NY 14580

Office: (585) 670 0507
Fax: (585) 735-4641
           

w.p.m@websterpsychmed.com
 

NEW PATIENTS:

 

Welcome to our practice! We pride ourselves on providing quality psychiatric care in a patient friendly atmosphere.  We ask that you complete a New Patient Packet and bring the completed forms, along with your insurance card, to your initial appointment. 

We will call to confirm your initial appointment two business days ahead of time.  It is necessary for you to confirm that you will be attending the appointment.  You must confirm by noon the business day before your appointment, otherwise we will schedule someone from our waiting list at that appointment time.  If you do not show or cancel after confirmation of the appointment, we reserve the right to not reschedule your appointment.

 Please print out and complete a New Patient Packet and plan to arrive 15 minutes early for your first appointment. 
    
    
    NEW PATIENT PACKET-Website.pdf
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NOTICE OF PRIVACY PRACTICES

The confidentiality of your personal health information is very important to us. 

NOTICE OF PRIVACY PRACTICES.pdf
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AUTHORIZATION FOR RELEASE OF INFORMATION:

Please use if you would like to add, update or revoke an Authorization for Release of Information that you have on file with our office. 


RELEASE OF INFORMATION BLANK- revised.docx
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INSURANCE:

We will bill your medical insurance for any office services provided; if your insurance plan determines that the service is not covered, you will be responsible for its full charge.  If your insurance fails to pay the submitted claim within 30 days, you will be responsible for the amount charged.  You are also responsible for checking with your insurance plan for any prior authorization required.  If your insurance denies the claim for lack of prior authorization, you will be responsible for the full charge of the service.  If we do not accept your health insurance, or if you do not have insurance, you will be responsible for the full charge of the service prior to your visit. 
 
PAYMENTS:

We only accept the following methods of payment: cash, MASTERCARD OR VISA.  We do not accept DISCOVER or checks at the front desk. 

If you have a deductible plan, you are responsible for paying your medical expenses out of pocket until you reach the deductible.  After that you may still be responsible for a percentage of the cost (coinsurance) until you reach an out of pocket maximum. 

We will contact your insurance company prior to your appointment to determine whether your deductible or out of pocket maximum has been met.  If not,  we will be collecting payment from you at the time of service.  Failure to pay a deductible, coinsurance or copay at the time of service may result in the cancellation of your appointment and be considered a missed appointment.  There will also be a $15 late fee added to your account.  The costs for visits at our office is determined by your insurance company, and these rates can vary by plan.  We encourage all patients who have a deductible plan to enroll in a Health Spending Account (HSA). We accept HSA Visa and MasterCard for payment.

Mailed checks returned for insufficient funds will result in a $25 returned check fee added to your account.


APPOINTMENTS: 

Your appointment time is reserved especially for you and it is your responsibility to notify us if you are unable to keep your scheduled appointment.  If you fail to notify us of cancellation at least 48 hours prior to a scheduled appointment, or if you do not show for a scheduled appointment, we will charge your account the full amount of the visit, ranging from $100-$175.  This fee is due prior to your next scheduled appointment.  This fee may be waived one time per calendar year in case of an emergency.  If there is a second emergency cancellation in a calendar year, you will be charged for the second cancellation.  In order to be compliant with our 48 hour cancellation policy, you must cancel your appointment by 5:00 pm two business days prior to the scheduled appointment.  For your convenience, we have a 24 hour answering machine; messages are time stamped and cancellation messages will need to be compliant with our policy.  If you are charged for three No Shows and/or Late Cancellations in one year, you will be subject to dismissal from the practice.

If you arrive late for a scheduled appointment, we reserve the right to reschedule your appointment and charge you for a missed appointment. 

MEDICATIONS: 

We require an office visit a minimum of every 3 months and will prescribe a maximum 3 month's supply of medications for non-controlled substances.  For controlled substances, we require an office visit every 30 days if the medication is being used regularly and not on an "as needed" basis. It is the responsibility of the patient to ensure our office is directly notified of medication refill requests ONE WEEK prior to running out of a medication.  We require that patients contact our office directly for requests and you may leave a message on our dedicated refill request line.   We do not process medication refill requests after hours, on weekends or holidays. 

 

Please ask if you have any questions regarding our office policies.  Please contact Member Services at your insurance company if you have questions about your insurance plan. 

 

 

 

 

 

 

 

 

                                                                                                                                                     

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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