Medication Refill Policy
You must notify your provider during your face-to-face visit if you need a prescription renewal. Our provider will write enough prescription to last until your next appointment. No medication refills may be sent in after hours or weekends, and if it is done, it may require additional charges. Refills for missed appointments, no shows or lost prescriptions will not be completed between appointments. Please make appointment ASAP to see your clinician.

Emergency Telephone System:
The Clinician/Therapist or one of their associates is available daily for emergency telephone contact. He/she can be reached through our office during working hours. We value your contact in real emergencies as it may smooth your treatment. After hours/ weekend emergency phone number: please call 911 or go to the nearest emergency room. Please call our main line during working hours: (407) 410-8621. Additionally, routine clinical updates or questions should otherwise be discussed at your appointment.

Record Transfers:
If transferring to our office from another practice, please request that the records be released to our office before your first visit in our office. If transferring out of our office, please download, complete, and submit our Authorization to Disclose/Release Information form. The form should be signed by the parent or legal guardian if the patient is under 18 years of age and by the patient themselves if over the age of 18. There is a charge fee for the copying and releasing of medical records that is due upon submission of the request.

Missed Appointments / Late Cancellations:
If you are unable to keep a scheduled appointment, call the office a minimum of 24 hours ahead to cancel or reschedule that appointment. Failure to cancel your appointment without 24-hour notice will result in a $25-$50 fee (depending on insurance). Failure to cancel your appointment without 24-hour notice may also result in discharge from this practice. Please see our Cancellation Policy.

Co-payments and Insurance Cards:
At every office visit, be prepared to show your current insurance card and make a co-payment if your plan requires so. If your child is sent with a childcare provider, please make sure that that person is prepared to make the co-payment, also a consent paper from the parent/guardian authorizing the companion to bring the minor to the office/Telepsych visit and show a photo Identification.  

I. D. Identification: For all clients and/or their legal guardians, a state issued photo I. D. is a mandatory requirement in our practice or we may need to reschedule your appointment. We will collect your deductible, copay, or percentage (if PPO) at the time of service. Please be prepared to pay with cash (in office visit), debit card/credit card (Visa, MasterCard or Discover) for Telepsych visits. It is ultimately your responsibility for anything not covered by insurance.

Walk-In Appointments:
All visits in our office or through telepsychiatry platform are by appointment only. Walk-in appointments will be considered on a case by case. Please call the office line and we will make every effort to schedule you the earliest appointment. Late to Appointment: If you are more than 15 minutes late to your appointment, we may need to reschedule you. As a courtesy to you, we may call or Text (text charges may apply, please check with your phone career and if you do not want this, please let us know) you within 1-4 days before your scheduled appointment to remind you of your appointment; however, it is ultimately your responsibility to remember your own appointments. ALL APPOINTMENTS MUST BE CANCELED 24-HOURS IN ADVANCE OR BE GUARANTEED YOU WILL BE CHARGED A FEE OF $25 – $50. This includes any “no-show” appointments. This fee must be paid before your next office visit.

In making this assignment, I understand and agree that if payment is not received from my insurance company within 45 days of the date of service, I am aware that I am fully responsible for the entire balance.

BILLING, FEES, APPOINTMENTS, NO-SHOWS, TARDINESS, CANCELLATIONS
(1) Please remember to cancel or reschedule 24 hours in advance. You will be responsible for the entire visit fee if cancellation is less than 24 hours. You are responsible to set the type of appointment reminders to receive through the mandatory portal.
(2) Practice consents, new patient intake questionnaires, and insurance name and identification/group numbers MUST BE completed and sent in at least 48 hours prior to your scheduled appointment.
(3) You have a 15-minute grace period prior to being considered a No-Show and/or Late. Showing up for an appointment after the 15-minute grace period is considered late. You will be charged the entire visit fee.
(4) The standard meeting time for appointments are between 15-60 minutes. It is up to you, however, to determine the length of time of your sessions. Requests to change the session needs to be discussed with the provider so that the time can be scheduled in advance.
(5) A $20.00 service charge will be charged for any attempted payments via credit card and payments returned for any reason by bank for special handling.
(6) Clients using credit card payments for cash pay visits will be charged an additional $5.00 transaction fee.
(7) Cancellations and re-scheduled appointments will be subject to a full charge if Alpha Life Mental Wellness Center DOES NOT RECEIVED AT LEAST 24 HOURS ADVANCED NOTICE. If you are in a different time zone, you are responsible to visit Alpha Life Mental Wellness Center on an Eastern Standard Time Zone. This is necessary because a time commitment is made to you and is held exclusively for you.
(8) If you are late for an appointment within your 15-minute grace period, you may lose some of that appointment time.
(9) ** You are responsible to contact your insurance carrier to verify your tele-psychiatry (videoconference) eligibility benefits. If you have an appointment and seen during your scheduled appointment time, then realize your insurance DOES NOT cover your scheduled visit. You will be charged the full visit costs. **
(10) All outstanding balances are expected to be paid in full at the time of your scheduled appointment.
(11) If you have deductibles to meet prior to your insurance paying visit costs. You are responsible for all visit charges.
(12) Credit Card Authorization: Upon receipt of entering my credit card information and my signature, I authorize {Alpha Life Mental Wellness Center, LLC.} to bill all charges for which I am financially responsible, including no-show visits. I further understand that my credit card will be charged for any outstanding balance including a 1.5% interest late charge with no waiting period. Subsequently, I authorize {Alpha Life Mental Wellness Center, LLC}, to bill my account balance to my credit card immediately, and thereafter in the event a balance exists. I understand that my credit card will not be charged if I choose to pay for treatment in person at the time of each appointment.
(13) I will notify {Alpha Life Mental Wellness Center, LLC} immediately of any changes to my credit card. I acknowledge that I am fully responsible for all services received and any late fees accrued at {Alpha Life Mental Wellness Center, LLC}.
(14) You are responsible for any unpaid balances.

DISABILITY, TRANSPORTATION, UTILITY COMPANY, etc. PAPERWORK
(1) ** Paperwork completion for disability of any kind and/or paperwork for community resources will cost $50 -200.00 per occurrence. Paperwork of any kind will not be completed prior to at least 6 months frequent and completed visits. Full compliance with appointments is mandatory for paperwork completion. **
(2) Letter request fee for work, school, etc. is $50-100.00 per request. Correspondence may take up 5-7 days to be completed.

WE DO NOT COMPLETE DISABILITY PAPERWORK, however, YOUR RECORDS and/or A DIAGNOSIS LETTER CAN BE PROVIDED. Please utilize your psychologist, therapist, or counselor for the completion of disability paperwork.

ALL SCHEDULED VISITS
(1) You may be required to return at least bi-weekly for medication evaluations.
(2) Three no-shows will jeopardize your ability to continue receiving care from Alpha Life Mental Wellness Center, LLC.
(3) Alpha Life Mental Wellness Center, LLC. Will alert you of your upcoming appointment through our patient portal, usually via texts. However, you are responsible for selecting appointment notification reminders by way of text, voice and/or email appointment reminders. You must select the form of preferred appointment reminders or choose to opt out of any of these. If you are unable to keep your appointment, please have the courtesy to cancel your appointment at least 24 hours in advance.

MEDICATION REFILLS
(1) Medication refill (except for controlled substances) outside of appointment schedule requires a $35 fee.
(2) Schedule an appointment if you are having side effects with your medications. Medications will NOT be adjusted or changed over the phone, without a visit.

TELEPHONE ACCESSIBILITY
(1) If a true emergency situation arises, please call 911 or any local emergency room.
(2) Telephone consultation calls may be considered. $125.00 /20 minutes increments ($375.00/hour) will be charged for non-clients outside of routine scheduled evaluation/medication management appointments.

SOCIAL MEDIA AND TELECOMMUNICATION
Due to the importance of your confidentiality and the importance of minimizing dual relationships, we do not accept friend or contact requests from current or former clients on any social networking site (Facebook, LinkedIn, etc.). We believe that adding clients as friends or contacts on these sites can compromise your confidentiality and our respective privacy. It may also blur the boundaries of our therapeutic relationship. If you have questions about this, please bring them up when we meet and we can talk more about it.

ELECTRONIC COMMUNICATION
We cannot ensure the confidentiality of any form of communication through electronic media, including text messages. If you prefer to communicate via email or text messaging for issues regarding scheduling or cancellations, we will do so through secure messaging within the client’s portal. While we may try to return messages in a timely manner, we cannot guarantee immediate response and request that you do not use these methods of communication to discuss therapeutic content and/or request assistance for emergencies.

Services by electronic means, including but not limited to telephone communication, the Internet, facsimile machines, and e-mail is considered telemedicine. Telemedicine Act, telemedicine is broadly defined as the use of information technology to deliver medical services and information from one location to another. If you and your provider chose to use information technology for some or all of your treatment, you need to understand that: (1) You retain the option to withhold or withdraw consent at any time without affecting the right to future care or treatment or risking the loss or withdrawal of any program benefits to which you would otherwise be entitled. (2) All existing confidentiality protections are equally applicable. (3) Your access to all medical information transmitted during a telemedicine consultation is guaranteed, and copies of this information are available for a reasonable fee. (4) Dissemination of any of your identifiable images or information from the telemedicine interaction to researchers or other entities shall not occur without your consent. (5). Kareo, the telemedicine platform does not record your video conference session. There are potential risks, consequences, and benefits of telemedicine. Potential benefits include, but are not limited to improved communication capabilities, providing convenient access with use of technology to up-to-date information, consultations, support, reduced costs, improved quality, improved access to treatment, better continuity of care, and reduction of lost work time and travel costs.

Effective treatment is often facilitated when the therapist gathers within a session or a series of sessions, a multitude of observations, information, and experiences about the client. Providers may make clinical assessments, diagnosis, and interventions based not only on direct verbal or auditory communications, written reports, and third person consultations, but also from direct visual and olfactory observations, information, and experiences. When using information technology in therapy services, potential risks include, but are not limited to the provider’s inability to make visual and olfactory observations of clinically or therapeutically potentially relevant issues such as: your physical condition including deformities, apparent height and weight, body type, attractiveness relative to social and cultural norms or standards, gait and motor coordination, posture, work speed, any noteworthy mannerism or gestures, physical or medical conditions including bruises or injuries, basic grooming and hygiene including appropriateness of dress, eye contact (including any changes in the previously listed issues), sex, chronological and apparent age, ethnicity, facial and body language, and congruence of language and facial or bodily expression. Potential consequences thus include the provider not being aware of what he or she would consider important information, that you may not recognize as significant to present verbally the provider.

MINORS
If you are a minor, your parents may be legally entitled to some information about your therapy. I will discuss with you and your parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

TERMINATION
Ending relationships can be difficult. Therefore, it is important to have a termination process to achieve some closure. The appropriate length of the termination depends on the length and intensity of the treatment. I may terminate treatment if I determine that the psychiatric treatment is not being effectively used, you need a higher level of care, for aggressive behavior or if you are in default on payment. I will not terminate the therapeutic relationship without first discussing and exploring the reasons in-person, notifying you by certified mail, or email for the purpose of terminating. If you are non-compliant with mandatory treatment recommendation (labs, PCP visits, urine drug screens, follow-up visits, etc.) or if you need a higher level of care, you are subject to a termination. If treatment is terminated for any reason or you request another provider, I will provide you with a list of qualified mental health providers to treat you. You may also choose someone on your own or from another referral source.

Should you fail to schedule an appointment more than 90 days out, unless other arrangements have been made in advance, for legal and ethical reasons, we must consider the professional relationship discontinued.