Forms & Policies
Office visits are by appointment only and vary according to each practitioner’s schedule. We do impose a fee for appointments missed or cancelled with less than 24-hours notice. We have immediate openings and offer services to all age ranges. Adults over the age of 18 MUST make their own appointments. Children under the age of 18 MUST be accompanied to all appointments by a parent or legal guardian.
All prescription refills must be called in a minimum of 5 business days before your medication runs out. We do not accept prescription refills from walk-in patients. When calling for a prescription refill, or any questions relating to your prescription your call will always go to voicemail. Phone requests obtained after 2:00 p.m., will be handled the next business day.
For calls that are an emergency during office hours press 0 to speak to the support staff. For emergency calls after business hours you will need to contact your provider directly. For calls in which you have questions for your provider that is non- emergent the support staff will take a message and notify the doctor of your call. You will be asked to provide the staff with as much information as possible during your phone call via a message in your chart, immediately after or during your conversation with the nursing staff. Remember when the providers are in session with a patient, they cannot be disturbed. The providers answer their messages throughout the day and you will get a return phone call as soon as your message has been answered.
Co-pays are to be paid at the time of your appointment, per your insurance contract. Co-pays for mental health coverage do vary from one carrier to another, review the back of your insurance card and contact your mental health carrier for questions if you have any questions regarding your co-pays or authorizations.
Private pay patients are expected to pay for services at time of visit.
There is a fee of $10.00 for NYS disability forms, as well as for other disability forms that are 1 page or less. More complex forms will be charged up to $25.00, depending on the length and time involved to complete the form. Your records, if copied, will cost $0.75 per copied page. Records requested by other physicians or health professionals rendering active treatment are free of charge. Dictated reports by you clinician will incur a charge based on the amount of time spent on producing the document. Court appearances are charged by the half-day and will differ from clinician to clinician.
Our patient forms are available on-line. You will need Adobe Reader to download these forms.
Download free Acrobat Reader DC software.
- Adult History & Personal Data Questionnaire
- Child and Adolescent Psychiatry Intake Assessment
- Notice of Privacy Practices
- Office Policy Form
- Authorization for Disclosure of Protected Medical Information Form
- HealtheLink Consent Form
- Authorization for disclosure of Protected Health Information Form & Psychotherapy Notes
- Patient Financial Policy
- Controlled Substance Agreement
- Patient Agreement
- Blue Cross/Blue Shield
- Independent Health
- United Behavioral Health
- Lifetime Benefit Solutions (RMSCO)
We do not participate with any Medicaid or any Medicaid managed care plans.
Availability of Written Statement of Fees
If I do not participate in the network of your healthcare plan, a written statement of fees for non-emergency services is available upon request.
Because I am not a participating physician in your healthcare plan, your healthcare plan may (i) not cover out-of-network services at all, (ii) impose higher deductible and/or copayments for out-of-network services or (iii) reimburse you for a lesser amount than my fees. You are responsible for payment of the full fees regardless of what reimbursement you may or may not receive from your healthcare plan.
We maintain affiliations with the following hospitals:
- BryLin Hospital (Dr. Martin & Dr. Cartagena ONLY)