Desai Health

I agree to receive practice updates and new services offered.

Please note that a court appointed legal guardian or healthcare proxy must be in attendance with a minor patient or a patient legally disabled who is appointed a healthcare proxy to make medical decisions on their behalf. If there are any custody documents for a minor child, they must be provided prior to the first appointment. Any documentation may be electronically uploaded via the file upload section of this online intake.

CONSENTS AND AUTHORIZATIONS

CONSENT TO TREAT: I hereby consent to examination and treatment by my health care provider at the office of Chirag V. Desai, MD, LLC (dba Desai Health). I understand that my healthcare provider may access medical information about my medication use from electronic prescribing software and databases. I hereby affirm that I am of legal age and otherwise competent to consent to medical treatment. If not, the person signing below represents that such person as the parent, legal guardian or person otherwise allowed by law to consent to the examination and treatment of the patient and by their signature hereto consents.

AUTHORIZATION AND ASSIGNMENT OF BENEFITS: I hereby authorize the office of Chirag V Desai, MD, LLC (Desai Health) to bill my insurance for services rendered and to release any information that may be required to secure payment for charges incurred by me or on my behalf. I authorize payment directly to my provider of any insurance benefits otherwise payable to me and in the event I receive payment from my insurance carrier, I agree to endorse any payment I receive over to Chirag V Desai, MD, LLC (Desai Health). I also authorize the release of any information to county, state, or federal public health agencies, as required by law.

Telehealth Patient Consent Form

Telehealth, also known as Telemental Health or Telebehavioral Health, is the delivery of mental health services using interactive audio and visual electronic systems between a provider and a patient that are not in the same location. These services may also include electronic prescribing, appointment scheduling, communication via email or electronic chat, and distribution of patient education materials. Desai Health utilizes secure, encrypted audio/video transmission software to deliver telehealth.

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

1. I have the right to withhold or withdraw consent at any time without affecting my access to future care, treatment, services or benefits to which I would otherwise be entitled.

2. The laws that protect the confidentiality of my personal information also apply to telehealth. As such, I understand that the information disclosed by me during the course of treatment is generally confidential. However, there are both mandatory and permissive exceptions to confidentiality including, but not limited to, reporting of 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. I also understand that the dissemination of any personally identifiable images or information from the telehealth interaction to other entities shall not occur without my written consent.

3. I understand that there are risks and consequences from telehealth, including, but not limited to, the possibility, despite reasonable efforts on the part of the provider, that: the transmission of my personal information could be disrupted or distorted by technical failures, the transmission of my personal information could be interrupted by unauthorized persons, and/or the electronic storage of my personal information could be unintentionally lost or accessed by unauthorized persons.

4. Telehealth may not be as complete as face-to-face services. I understand that if my provider believes I would be better served by another form of intervention (e.g., face-to-face services), I may be referred to a mental health provider who can provide such services in my area. I also understand there are potential risks and benefits associated with any form of psychiatry or psychotherapy and that despite my efforts and the efforts of my provider, my condition may not be improved, and in some cases may even worsen.

5. I understand that I may benefit from telehealth via improved access to care and more efficient evaluation and management from the use of telehealth in my care, but that no results can be guaranteed or assured.

6. I understand that I have the right to access my medical information and records in accordance with Florida law.

Desai Health will bill insurance for telehealth services; however, it is the responsibility of the patient (parent/guardian) to verify coverage of telehealth prior to services being rendered.

By signing this document, I agree that certain situations, including emergencies and crises, are inappropriate for telehealth services. If I am in crisis or in an emergency, I should immediately call 9-1-1 or seek help from a hospital or crisis-oriented health care provider/facility in my area. I also agree not to record any telehealth sessions without written consent from my provider and understand that my provider will not record any sessions without my written consent.

Patient Name: _________________________________________

Signature: ___________________________________ Date: _______________________

Relationship of the signer to the patient: _____ self _____ parent/guardian _____ legal representative

If you have insurance, we will make every effort to assist you with your carrier to make sure your treatment is authorized and reimbursement
Is received. However, our professional services are rendered to you, not the insurance company. Therefore, payment for services is ultimately your responsibility. If your insurance company fails to pay, for any reason, it is your responsibility to pay for services rendered and such payment is not contingent on settlement, judgement, or insurance payment by which you may recover said fees.

ALL CO-PAYMENTS ARE TO BE PAID AT THE TIME OF THE VISIT. Any exceptions are at the discretion of the provider and will need to be agreed to prior to being seen. Applicable deductibles may be required at the time of the visit or may be billed to you after insurances has processed. If you fail to make timely payments on your account, as agreed upon, your account will be turned over to a collection agency and you will be assessed a 40% collection fee. If your account is placed with a collection agency you will be discharged from the practice.

Our office must be notified of any insurance changes PRIOR to your next appointment so that we can verify eligibility and benefits. If you do not inform us of any changes, you will be responsible for any charges not covered by your insurance company.

There is a $50 fee for all returned checks. Returned checks are not re-deposited and if not paid may be turned over to a collection agency of the State Attorney’s office. After your 2nd returned check we will require payment in the form of cash or credit card only.

Self-pay patients are billed per amount of time scheduled and payment is expected prior to seeing your provider. In case of late arrival, you will still be billed for the full amount of time originally scheduled.

Self-pay Fees:
Evaluation: M.D. = $300 APRN = $250 THERAPIST = $200

Follow-up visits: M.D. = $175 APRN = $150 THERAPIST = $150

Phone Consults: M.D. = $65 per 10 mins APRN = $55 per 10 mins THERAPIST = $25 per 10 mins

Letters/Forms: fees based on complexity and time spent on completion

Request for Emotional Support Animal: Our office does not provide medical documentation for emotional support animals.

You are expected to arrive for your appointment 5-10 minutes early to complete the check-in process and address any issues, prior to being seen. As a courtesy to our patients, we offer an appointment reminder service. However, if for any reason our office fails to call you, you are still responsible for keeping the appointment.

If you arrive more than 10 minutes late for a 30-minute appointment, or 20 minutes late for a 60-minute appointment, there is no guarantee that you will be seen. Accommodation will be at the provider’s discretion and your session will still end at the appointed time.

Please provide 24-hours’ notice to CANCEL appointments. For Monday appointments (or Tuesday if Monday is a holiday), cancellations must be made by NOON the Friday prior to the weekend. Cancellations with less than 24-hour notice and appointment no-shows will be assessed a fee equal to the self-pay rate (see self-pay fees above). These fees must be paid prior to, or during, your next scheduled visit; waiver of these fees may be made if we are able to fill the spot with another client; otherwise waivers will be at your provider’s discretion only.

Please provide 24-hours’ notice to cancel appointments. Each time a patient misses an appointment without providing proper notice, another person is prevented from receiving care. As Desai Health often has a waiting list, timely notification of cancellation allows for someone else to be scheduled. Your time is very valued, and we will always do our best to have you scheduled on short notice with cancellation slots when needed if they become available. We appreciate the opportunity to do that for others as well.

Desai Health charges the full cost of your session for all no-shows and late cancellations with less than 24-hour advance notice. If you are utilizing insurance, please note that this fee is our standard self-pay rate and NOT your insurance co-pay amount.

Payment of a No-Show or Late Cancellation fee is due prior to or at the time of your next appointment. If you have a credit card on file, charges will be billed to that card. Multiple no-shows and/or late cancellations may result in discharge from our practice.

Evaluation No Show/Late Cancellation Fees:
M.D. = $300
Ph.D./APRN = $250
LMHC/LCSW = $200

Follow-up visits No Show/Late Cancellation Fees:
M.D. = $175
ARNP= $150
THERAPIST = $150

WE DO NOT ACCEPT REFILL REQUESTS FROM PHARMACIES and all such requests will not be acknowledged. Please ask the pharmacy to take your prescriptions off their auto-refill system. The patient (or parent/guardian) must contact the office for all refill requests. Call 904-638-8164 or send an email to [email protected]. You will need to provide the patient’s name, the dosage and directions for each medication, and the pharmacy name and location. Do not email your provider directly with refill requests – these requests will not be acknowledged.

Refill requests can take up to three (3) business days to process and there are no guarantees that urgent demands for refills will be met within this 3-day window. A fee of $50 may be charged if your refill request is due to missed/rescheduled appointments, lost prescriptions, or urgent/same day requests.

Refills may be denied if you have not been seen in more than four (4) months. You may need to be seen for re-assessment before medications can be prescribed/refilled.

Your provider may choose NOT to prescribe controlled substances (i.e., Xanax, Adderall, etc). Please be aware that your provider can monitor if you have received any controlled medications prescribed by other providers. Patients who misuse, overuse, or abuse, any medications will be discharged from the practice, or denied entry into the practice.

To ensure adequate medical oversight and practice in accordance with the accepted standards of care, follow-up appointments will be determined by your provider based on clinical acuity. You will need to be seen at least every three to four months unless otherwise indicated by your provider. If you have not been seen in six (6) months or more, your chart will be closed, and you will be discharged from the practice. A return to care would be at the discretion of, and upon approval from, the rendering provider

Noncompliance with your provider’s treatment plan and/or recommendations, including multiple missed appointments, will result in discharge from the practice.

We will gladly schedule multiple follow-up visits for therapy; however, if two appointments in a row are missed, without explanation, any remaining scheduled/standing appointments will be cancelled.

A parent or guardian MUST be present at the time of any minor child’s medication management appointment. Medication changes cannot be made without parental consent.

We do not provide forensic psychiatry services and will not get involved in custody or other court-related matters. If any of our providers are subpoenaed to appear in court, you will be responsible for their hourly rate and any associated legal fees.

Always remember: If you have a potentially life-threatening emergency and/or need help immediately, call 911 or go to the nearest emergency room. You may also call 211 for United Way’s crisis hotline or 1-800-273-8255 for the National Suicide Prevention Lifeline.

If you have non-emergent concerns after hours, you can leave a message or send an email to [email protected]. Messages and emails will be checked the next business day. On workdays, when the office is open, messages and emails are checked frequently throughout the day.

Providers return calls according to clinical acuity and usually at the end of the day. Please be aware that if your concern is complex or requires lengthy discussion you may be asked to schedule an office appointment or be billed for a non-visit phone consult. Phone consults are not covered by insurance. Please refer to the Administrative and Financial Agreement for fee information.

If any provider, or employee, calls you from the personal cell phone, and you are able to obtain the phone number, DO NOT use that number for ANY reason. We ask that you always contact the office with appointment and refill requests or clinical concerns. Please do not email the providers directly.

We will update our website (www.desaihealth.com) and Facebook page (fb.me/desaihealth) with any unscheduled office closures.

I hereby attest that I have read and understand the information provided to me regarding the Office Policies, and I agree to abide by these terms and conditions. I understand that if the above policies are not adhered to, the providers at Desai Health will not be able to provide my care and I may be discharged from the practice.