Patient Consent Policy Questionnaire

INTEGRATIVE AND HOLISTIC CARE

The Center for Integrative Psychiatry (CIP) practices a holistic, patient-centered form of psychiatry that blends modern medical science with traditional and alternative healing methods. It focuses on the mind-body-spirit connection and seeks to address the root causes of mental health issues rather than merely suppressing symptoms.

CIP’s approach integrates Ayurveda, Functional Medicine, nutrition, herbal therapy, exercise, meditation, and acupuncture with conventional psychiatry. Treatment plans are personalized and may include medications, supplements, diet and lifestyle changes, psychotherapy, and stress management techniques. Patients are encouraged to actively participate in their care alongside the clinical team.

CIP may use advanced lab testing (e.g., nutrient and genetic analysis) that goes beyond what conventional psychiatry typically offers. While these tests and supplement recommendations may not be FDA-evaluated or universally accepted, they are based on current scientific research. Patients are advised to maintain a relationship with a primary care provider for other medical needs.

All medications, nutraceuticals, and supplements are recommended in good faith but come with potential risks. Patients must inform providers of any allergies or pregnancy and avoid driving or operating machinery if drowsiness occurs. CIP assumes no liability for supplement use, and results of treatments are not guaranteed, as medicine is not an exact science.

You have the right to be informed about your health condition(s) and recommended treatment, along with the potential benefits, risks and hazards involved.

You, the undersigned, hereby request and consent to examination and treatment with the licensed psychiatric and integrative physicians and providers of this clinic, who may serve as substitutes for one another in cases of your primary provider’s absence, hereafter called allied health care providers.

You allow CIP to exercise its best clinical judgment in my case based on the information available at the time of the visit and again that all integrative treatment recommendations and all other recommendations are optional, and you may choose to refuse to accept or implement them.

● I consent to undergo diagnostic tests recommended by my provider that are necessary to help evaluate and treat my condition.
● I understand that during the course of my care, it may be necessary to perform random, unannounced tests including but not limited to: urine drug screens, urinalysis, blood work, EKG, imaging, neurofeedback, or any other test appropriate for the provision of continued care.
● Should I refuse to consent to such tests, or should my urine toxicology and/or other tests show abnormal results for any reason including, but not limited to, the presence of an unexpected substance or absence an expected substance), this may be considered, at the sole discretion of the provider or the clinic, as non-compliance with treatment recommendations.
● In such cases, CIP or its affiliates may exercise their right to discontinue providing services and recommend other providers who could take over providing care.

● I understand that telehealth services may be applicable to me if I am in a different location than the provider. However, I acknowledge that for televisits, I will be located within the borders of the State in which my care is provided.
● I understand that I may have to pay the cost of my appointment in advance before a telehealth session commences.
● I understand that telehealth sessions are conducted over a secure, HIPAA-compliant platform and may be recorded for accurate note-taking and documentation purposes.

● If you wish to contact your therapist or provider in between sessions, you may leave a message on the patient portal and this will be addressed within 24 hours.
● If an urgent or emergency situation arises, please call 911 or go to the nearest emergency room or urgent care facility.
● Patients are not allowed to have any connections with their providers or therapists on any social networking site to maintain the boundaries of the therapeutic relationship and ensure confidentiality and patient privacy.
● The standard meeting time for psychotherapy is just under an hour according to corresponding insurance billing codes. Requests to change the 50-minute session need to be discussed with the therapist in order for time to be scheduled in advance.
● If you have any questions or concerns about your counselor, or wish to file a complaint, you may contact the Texas Behavioral Health Executive Council at 1801 Congress Avenue, Suite 7.300, Austin, TX 78701. Phone: (512) 305-7700 | Toll-Free: 1-800-821-3205 | Website: https://www.bhec.texas.gov

Parents or legal guardians of minor patients may be legally entitled to the patient’s medical information. Providers and therapists will discuss with the patient and parents what information is appropriate for them to receive and which issues are more appropriately kept confidential.

CIP reserves the right to terminate a patient from our care under certain ethical, clinical, and administrative grounds, provided that proper notice and continuity of care are ensured to avoid patient abandonment.
Grounds for termination include, but are not limited to:
1. NONCOMPLIANCE OR REPEATED NO-SHOWS
2. NON-PAYMENT OR INSURANCE ISSUES
3. ABUSIVE, THREATENING, OR DISRUPTIVE BEHAVIOR
4. DRUG-SEEKING OR MISUSE OF CONTROLLED SUBSTANCES
5. BREACH OF CLINIC POLICIES OR AGREEMENTS
6. CHANGE IN MEDICAL NEEDS OR PROVIDER-PATIENT FIT
7. RELOCATION OR INABILITY TO REACH THE PATIENT

Upon termination of care, the clinic will provide a 30-day written notice, allowing the patient time to find another provider.

The patient will be provided with an adequate supply of medication/s, if applicable, and referrals or resources for alternative providers.

CIP reserves the right to refuse treatment to a patient who cannot be adequately assisted with his/her condition, in accordance with our policy against prescription of narcotic substances and other highly addictive agents such as benzodiazepines, stimulants, etc. or for any other reason at the sole discretion of CIP. In the event that the patient has been taking such medicines, if the provider recommends a taper or discontinuation, the patient is expected to follow through with such recommendations. All effort and support (as are possible) will be provided by CIP to help patients throughout the taper and discontinuation process. Please note that such taper and discontinuation usually take months to allow the mind-body system to acclimate to a new state of function.

Your information. Your rights. Your responsibilities.

HIPAA, or the Health Insurance Portability and Accountability Act of 1996, is a US federal law that sets national standards for protecting sensitive patient health information. It establishes rules for who can access and share protected health information (PHI) and how it must be secured.

Your rights

✔ Obtain a copy of your medical record in paper or electronic form
✔ Make corrections to your medical records
✔ Request confidential communication and limit shared information
✔ Provide a list of authorized person/s whom we can shared your medical information with
✔ Get a copy of our policies and privacy notice
✔ Choose a representative to make decisions on your behalf
✔ File a complaint if you believe your rights have been violated

All information provided to CIP staff is strictly confidential and HIPAA regulations are enforced, except in the following circumstances:

● If there is a threat of harm to self or to others
● Your insurance company requests information about your treatment in order to process a reimbursement claim or certify care (when applicable)
● The patient authorizes the release of information by signing a release form naming the specific person/provider/facility to receive the information
● Certain circumstances where we are required by law to release patient information (e.g. court subpoena; suspicion of child abuse, elder abuse, or abuse of a person deemed incapacitated or incompetent, etc)
● In the rare instance where a judge may mandate testimony from CIP providers. In such situations, the involved client retains the right to refuse the involvement of the physician/therapist in legal proceedings
● If there is reasonable degree of certainty that patient cannot operate a motor vehicle or heavy machinery due to epilepsy, dementia, TBI or other dysfunction
● Discussion of treatment with other providers the patient currently sees with the goal of care coordination and formulation of appropriate treatment plan (unless specified not to do so)

Our Responsibilities

● We are required by law to maintain the privacy and security of your protected health information.
● We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
● We must follow the duties and privacy practices described in this notice and give you a copy of it.
● Some terms of this notice may change without prior notice. You may obtain a copy of the updated terms upon request. We may also notify you via the patient portal, text, or email if there are any changes.

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

CIP uses an electronic health record (EHR) system to record and store patients’ clinical information. This EHR system is secure and also abides by HIPAA laws/regulations. Any written records that need to be kept will be kept locked and will only be accessible to CIP-authorized staff.

Patients have the right to access or view their medical records. Time spent collecting, printing, copying, and summarizing the medical record will be charged an appropriate fee. For any concerns or questions regarding medical records, clients are encouraged to discuss them with CIP.

Prior to the initiation of any services, all patients are required to present a valid government-issued photo identification to verify their identity and to ensure accurate medical records, patient safety, and compliance with applicable regulatory requirements.

Website, Social media, Blogs

The information provided by the CIP website and blog or its affiliates; including printed materials, audio and video resources, is for educational purposes only and is NOT intended as a substitute for professional medical advice, diagnosis, or treatment.

Always seek professional medical advice from your physician or other qualified heath care provider with any questions you may have regarding a medical condition.

COMMUNICATION

● Phone: 972-212-5068
● Fax: 214-387-1214
● Website: www.texascip.com
● Email: info@texascip.com


You can reach the clinic through any of the above-mentioned means and we will make every attempt to address NON-EMERGENCY calls within 2 business days. Our operating hours are MONDAYS TO FRIDAYS, 8AM to 5PM CST. When leaving a voicemail, please include your full name, date of birth, callback number, and a short message stating the reason for the call.

Please be informed that email is NOT a secure means of communication and patients should exercise their judgment and caution regarding sharing of sensitive medical information via email. In such an event, CIP reserves the right to not communicate via email and instead use a more secure means of communication.

When calling for medication refills, please call at least 2 business days before you completely run out of supply, as we have a 48-hour turnaround time for processing medication refills.

In case of an emergency or urgent concern, please call 911 or 988 or go to the nearest emergency room.

Nutritional and Herbal Supplements through CIP

Under federal law, vitamins, minerals, herbs, and similar products are not classified as drugs, though they can significantly affect the body and should be used responsibly. Patients should inform all healthcare providers about any supplements or medications they use.

CIP may recommend specific brands after thorough research to ensure quality, purity, and effectiveness, even if they may cost more. We provide personalized counseling and recommendations for supplements to support nutrition and body function, while ensuring compatibility with any prescribed medications.

CIP may recommend specific brands after thorough research to ensure quality, purity, and effectiveness, even if they may cost more. We provide personalized counseling and recommendations for supplements to support nutrition and body function, while ensuring compatibility with any prescribed medications.

FINANCIAL AGREEMENT, PAYMENT POLICY & CREDIT CARD AUTHORIZATION

The Center for Integrative Psychiatry (CIP) is committed to serving our patients with professionalism and compassionate care. We expect the same commitment in return, including financial responsibility, timely attendance, and appropriate communication regarding scheduling changes.

By signing this agreement, you acknowledge that you have read, understood, and agree to the following terms:

1. Financial Responsibility

Patients are responsible for all charges incurred for services provided by CIP. This includes:
● Payment at the time of service
● Arriving on time for appointments
Providing at least 24 hours’ notice for cancellations or rescheduling
● Maintaining a valid payment method on file

CIP reserves the right to refuse scheduling if a patient:
● Is consistently late
● Has multiple no-shows
● Fails to respond to communication attempts
● Has unpaid balances
● Exhibits behavior inconsistent with a professional healthcare setting


For services rendered outside of CIP (radiology, labs, hospitals, surgery centers, physical therapy, rehabilitation facilities), it is the patient’s responsibility to verify in-network status with their insurance plan.

2. Insured Patients

1. Deductibles, copays, and estimated coinsurance are due at the time of service.
2. Copayments and estimated coinsurance amounts will be processed by 8:00 AM on the day of your scheduled appointment.
3. Charges are based on insurance information available at the time of service.
4. If insurance processing determines additional patient responsibility after claim adjudication, you authorize CIP to charge the remaining balance to your card on file once finalized.
5. If insurance cannot be verified, is inactive, or is out-of-network, the full session fee may be charged. Adjustmentswill be reconciled once insurance processes.
6. CIP submits insurance claims as a courtesy; however, all balances remain the patient’s responsibility.
7. It is the patient’s responsibility to verify coverage, benefits, exclusions, and plan limitations prior to services.
8. Claims denied due to lack of coverage cannot be resubmitted under alternative codes.

Outstanding Balances

● A $10 monthly re-billing fee will be applied to outstanding balances.
● Accounts unpaid after 30 days will be considered in arrears.
● After an additional 30 days without resolution, accounts may be referred to collections.
● We are willing to work with patients on structured payment plans when proactively requested.

3. Self-Pay/ Out-of-network Patients

● New Intake: $300
● Follow-Up or Therapy Session: $175

All charges are due in full on the day of service unless prior arrangements have been made.

Patients may request a Superbill to independently submit to their insurance for possible reimbursement. All laboratory or collaborating facility charges are billed separately and remain the patient’s responsibility. Integrative and holistic therapies are optional and elected at the patient’s discretion. Patients maintain the right to seek care from another provider at any time.

4. Cancellations, Late Rescheduling & No-Shows

● Late cancellation: less than 24 hours’ notice
● Fees:
- $50 – first occurrence (card on file required to reschedule)
- Full visit rate for subsequent late cancellations or no-shows:
● $300 initial appointment
● $175 follow-up or therapy

● These fees are not billable to insurance

5. Other Services & Fees

● Specialty Test Lab Handling: $65
● Letters / Forms (military, work, personal): $250
● Phone Consults (>2 minutes):
- $65 first 15 minutes
- $30 per additional 5 minutes
● Dispensary Products: Payment due at pickup; no refunds; prepayment required for shipping; shipping/handling applies
● Returned Checks (NSF): $50 service fee

6. CREDIT CARD AUTHORIZATION & CONSENT

To streamline care and prevent cumulative balances, CIP requires a valid credit or debit card on file for all patients.
Card information may be:
● Provided verbally to staff for secure entry into Bluefin, or
● Entered below by the patient (if applicable).

By signing below, I authorize CIP and any billing entity acting on its behalf to:
● Securely store my credit/debit card information via Bluefin
● Charge my card for copays, deductibles, and estimated patient responsibility at 8:00 AM on the day of service
● Charge remaining balances determined after insurance claim adjudication
● Charge fees for late cancellations, no-shows, or past-due accounts
● Charge preset payment plans or packages

If a payment is declined, reversed, or disputed:
● You remain responsible for the balance
● Updated payment information must be provided within 48 hours
● Future appointments may require prepayment
● Repeated declined payments may result in required prepayment for all future services

Unresolved balances may be referred to collections after reasonable notice.

I understand that:
● My card will not be charged outside the terms described in this agreement
● Providing my card verbally is optional but required for ongoing care
● This authorization applies to all current and future services provided by CIP unless revoked in writing

Card Information

By signing below, I, being the authorized cardholder, agree to the terms set forth in this agreement and agree to pay and authorize the practice to charge my credit card for the services provided, even those not reimbursed by my insurance carrier, if billed by the practice or reimbursed directly to me.

I further agree that I will provide a new valid card upon request to be charged for any payments in the event my card becomes invalid.

I further acknowledge that I have received, read, and understood the information outlined above.

By signing this form, you acknowledge that The Center for Integrative Psychiatry (CIP) has given you a copy of its Notice of Office Policies and Privacy Practices.

I have received a copy of the Notice of Privacy Practices. CIP has given me the opportunity to ask any questions about this notice, and all my questions have been answered. This authorization will remain in effect until canceled by me in writing. A copy of this authorization is as valid as the original document.