I hereby give my consent to undergo psychotherapy on a voluntary basis. I understand that I may discuss any concerns I may have regarding my treatment with my therapist and that I may withdraw from treatment at any time should I feel the need to do so. I understand that if there is no contact with the agency for 30 days, my case may be closed.
I understand that my insurance & fee responsibilities are as follows:  
• I understand that MFS has made every effort to verify my insurance coverage. However, I understand that my insurance is a contract between the insurance company and myself, and I am ultimately responsible for fees and/or charges not covered by my policy, or any changes in the rate the was originally quoted to MFS.  I should contact my insurance company personally to verify the accuracy of these fees.

• I give permission to MFS to use my name, social security number, diagnosis, session type (s), and date(s) of service for purposes of billing my insurance company.

• I agree to pay my fees at the time of service and to inform MFS of any changes in my insurance. We are contractually obligated by insurance contracts to collect your deductibles and co-pays at the time of your visit. We cannot waive and/or reduce the assigned insurance patient liability (co-pay, deductible, co-insurance) in order to comply with federal insurance regulations and law. Payment can be made via Cash, Check, Money Order, Visa, MasterCard, Discover, American Express, PayPal via the MFS website.

• I understand that if my account balance is not paid in 30 days I will be billed a statement fee.
 
• I understand that I may be charged the reasonable and customary fee from my insurance, or session fee for self-pay clients, for not canceling an appointment 24 hours in advance and/or for not showing up for my scheduled appointment.

• I understand that I will be charged $25 for any checks that are returned due to insufficient funds.
 
• I understand that my account may be turned over to a collection agency if I make no effort to pay my balance within 90 days.

• Requests for the completion of forms, documents, or special reports may be completed at the discretion of your therapist or psychiatrist and will be subject to an additional fee.

• Regarding the treatment of children with divorced parents: The responsibility of payment for treatment of the minor of divorced parents rests with the parent who seeks the treatment. Any court ordered responsibility judgment  must be determined between the individuals involved, without the inclusion of MFS.

• I understand MFS uses a variety of electronic communication methods including phone, text messages, e-mail to communicate with me for the limited purposes of appointments and available services. I authorize MFS to disclose limited protected health information to other persons who may answer my electronic communications such as phone, text messages, or e-mail. These may include information about appointments and available services. video/telephonic appointments.

• If I am receiving telehealth sessions, I understand that there are risks:
1. Risks may include (but not limited to) lack of reimbursement by your insurance company, technology dropping due to internet connections, delays due to connections or other technologies, or a breach of information that is beyond our control. Clinical Risks will be discussed in more detail with your clinician, but may include discomfort with virtual face to face versus in person treatment, difficulties interpreting non-verbal communication, and importantly, limited access to immediate resources if risk of self harm or harm to others. Your clinician will discuss the specifics of Telehealth with you before using the technology.
2. Telehealth is not meant for suicidal or homicidal high risk situations and it is recommended that you go to an emergency room or psychiatric hospital for an evaluation of higher level of care.

If I am receiving psychiatric services, my responsibilities are as follows:  
• I agree to inform my psychiatrist if I am pregnant, nursing, or planning a pregnancy.

• I agree to attend all scheduled appointments with the psychiatrist. I understand that if I fail to cancel an appointment with the psychiatrist at least 24 hours prior, I will be charged the following fee as my insurance company does not cover these fees:
Psychiatric Evaluation: $185 Medication Review: $65

• If I am seeking a refill on my medications, I agree to contact MFS at least 7 business days before I run out of my medication. Please note: Per MFS policy - we will not routinely refill medications over the telephone without the client attending regular visits with the psychiatrist.

• A fee of $20 may be charged for the refill of any prescriptions over the telephone.

• I understand that I am responsible for contacting pharmacist and/or physician if I have additional concerns regarding my medications.

• Regarding the treatment of minors: Prescription cannot be given to a child or adolescent without the consent of the Parent, Legal Guardian, DHS worker or Foster Care worker as applicable.

In the event of an emergency, I should contact the Macomb County Crisis Center: 586-307-9100, go   to the nearest hospital emergency room, or call 911 for assistance.