UPDATED CLINIC POLICIES

Asif Uddin, MD (“Dr. Uddin”) provides direct payment fee-for-service evaluations and treatments at and through KC Psychiatry & Primary Care, LLC (the “Practice”).

Please make note of the following policies:

WE DO NOT ACCEPT INSURANCE OF ANY KIND. THIS INCLUDES BOTH COMMERCIAL AND FEDERAL INSURANCE (i.e. Medicare, Medicaid).

“CONTACT INFORMATION
1.        Our office is open Monday-Thursday 9am-5pm. All correspondences outside of normal office hours will be addressed upon return to the office.
·      Please Note: Our email address has changed. For faster response, rather than call, we recommend you please send us a message at info@kcmedpsych.com. Please add this email to your saved contacts.
2.        If you are experiencing a medical emergency, please dial 911 or visit your nearest emergency room.
3.        If you are experiencing a mental health crisis, please dial 988 from a touch tone telephone to reach the
Suicide and Crisis Lifeline.

1. A new patient psychiatric evaluation is $400.00. Dr. Uddin will provide ONLY psychiatric services.

2. A comprehensive care evaluation is $500.00. Dr. Uddin will provide primary care, weight management (should it be desired), and psychiatric services.

3. A weight management evaluation is $400.00. Dr. Uddin will provide ONLY weight management services.

***PLEASE NOTE: All new patient evaluations require a $200.00 NON-REFUNDABLE deposit due at the time of scheduling. The balance is due at the time of the visit. No exceptions will be made. If full payment is not made at the time of the appointment, it will be considered a NO SHOW, and the $200.00 deposit will be forfeited.

1. Patients are required to be seen when Dr. Uddin deems appropriate.

2. All follow up appointments are $200.00, due at the time of the appointment. No exceptions will be made.

3. NO SHOWS will result in a charge of $100.00 due immediately.

4. Cancellations within 24 hours of a scheduled appointment will result in a charge of $100.00 due immediately.

*** In the event of an extenuating circumstance, discretion may be applied on a case-by-case basis.

5. If full payment is not made at the time of the appointment, it will be considered a NO SHOW and incur a $100.00 NO SHOW fee, required to be paid no later than 2 weeks after missed appointment.

1. We do not accept insurance in any form, commercial or federal (Medicare, Medicaid etc.)

2. Payment may be made via cash, credit or debit card, or HSA/FSA account. All patients are required an active card on file.

3. We reserve the right to charge the card for any outstanding balance.

4. We do not issue refunds for any rendered services.

5. We do not offer sliding scale or a payment plan in any form.

1. Please allow 48-72 hours for all refill requests.

2. Medication refills may not be honored if the patient has missed, cancelled, or rescheduled an appointment outside of the recommended time frame.

3. Extenuating circumstances may be considered on a case-by-case basis.

1. Please provide at least 72 hours to complete any paperwork requested.

2. Forms (i.e. FMLA, short term disability, ADA, etc.) required to be completed by Dr. Uddin will incur a charge of $50.00 due prior to completion. Renewals or extensions are $25.00.

3. Letters written to any entity or organization (i.e. school, court, work) will be charged at $25.00.

1. Dr. Uddin may terminate the care of a patient at his discretion at any time.

2. Three (3) missed appointments (No shows or cancellations/reschedule within 24 hours) will result in immediate termination of care.

FINANCIAL RESPONSIBILITY

I agree to pay ALL applicable fees for services and treatments rendered. I understand that service fees are subject to change at any time with notice to the patient, at the Practice’s discretion.

I also agree to be responsible for ALL costs and expenses, including court costs, attorney fees, and interest, should it be necessary for the Practice or Dr. Uddin to take action to secure payment of an outstanding balance owe.

NOTICE OF NON-COVERAGE OF SERVICES

I understand the Practice is a SELF-PAY ONLY business. The Practice and Dr. Uddin do not inquire or participate in any commercial, state, or federal insurance plans, including Medicare and Medicaid. As such, payment in full will be required with each visit, in accordance with the financial policy outlined above.

The Practice and Dr. Uddin DO NOT GUARANTEE COVERAGE/REIMBURSEMENT of any treatment(s) rendered, including procedures, medications, laboratory tests, or whatever else may be deemed medically appropriate. I acknowledge and understand that I am responsible to pay all costs incurred even if my insurance company determines that any services are not covered, excluded, or, in their opinion, unreasonable or medically unnecessary.

Furthermore, I understand and agree that the Practice and Dr. Uddin advise me to obtain and keep full health insurance coverage for myself. The services provided by Dr. Uddin or The Practice are not intended to replace any current or future health insurance coverage I may carry.

I understand that I should not submit any claims for any services provided or ordered by the Practice and/or Dr. Uddin to Medicare, Medicaid, or any other federal payor and any such CLAIMS MAY NOT BE REIMBURSED.

Should I have any questions or concerns regarding the policies and procedures, I may contact KC Psychiatrist directly.

Thank you,

KC Psychiatry & Primary Care, LLC