Candida Fink MD
4 Stanton Circle   New Rochelle NY 10804
Phone 877-534-1090  Fax 914- 560-2106
www.finkshrink.com

 Treatment Agreement

View/Print Treatment Agreement PDF

This form contains important information about my practice and how it works. We will review this form, along with the “Notice of Privacy Practices” at our first visit and I will ask you to sign this form to indicate that we have done this.  You can have a printed copy of both forms, or you can access them at any time at my website.

Office Policies and Procedures

Scheduling and Appointments

  • Initial appointments are scheduled through the office with my assistant Carol
  • Follow ups may be scheduled through Carol or with me in the office.
  • All patients receiving prescriptions must be seen regularly– even when stable.
  • After school/work appointments are scarce; please book in advance

Prescriptions

  • Due to state regulations, requests for controlled substance prescriptions take two business days to process  i.e. a Thursday request cannot be filled before the following Monday. 
  • Other prescription refills require at least one business day to process but please try to notify the office as soon as you can, to prevent delays.
  • If a medication requires a prior authorization please contact Carol with the insurance information to assist with this process

Phone Calls

  • I make every effort to return routine calls by the next business day but this is not always possible.
  • I am not in the office on Fridays so calls from late Thursday and Friday will usually be returned the following Monday.
  • For after-hours emergencies only call: 914-819-2854
  • Please note: There may be times when I cannot return an emergency call right away. If there is a serious emergency, such aggression or self -harm, leave a message at the office  but then call 911.  
  • If you are calling during business hours (Monday through Thursday, 9:00 am to 5:00 pm), and you have an urgent matter, please do not call the emergency number – call the office and Carol will be able to reach me.
  • For urgent matters that arise on Friday, please leave a message at the office but also leave one on the emergency line:  914-819-2854.

Email

  • Email communication is used to expedite communications around routine matters,
  • Email is not for urgent or emergent concerns.  Please use the phone, as outlined above. to reach us for urgent or emergency concerns
  • Every effort is made to return email within one business day
  • Every effort has been made to keep email communications confidential, but this cannot be fully guaranteed due to the electronic nature of the communication. 

Billing and Cancellation Policies

HEALTH CARE PLAN PARTICIPATION STATUS

I am not a participating physician in any healthcare plans. 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 not cover out-of-network services at all, may impose higher deductible and/or coinsurance, or may reimburse you less than my fees.

You are responsible for payment of the full fees regardless of what reimbursement you may or may not receive from your insurance company.

Payments

Payment is made at time of service – we accept checks and all major credit cards.  If you are the parent of a teen or young adult who will be coming without you to the appointment please make sure that arrangements have been made in advance for payment.  We can keep your credit card information on file to expedite this process.  Please contact the office to make these arrangements.

 Cancellations and Missed Appointments

The office requires at least 24 hour advance notice if you are not able to attend your appointment.   We try to be flexible around illness and weather issues but otherwise there will be a fee of $75.  Appointments missed without notification incur a fee of $125.

 Phone or Video Chat Appointments

Short phone calls are not billed.  If a call requires more than 5 minutes we will ask you to schedule a phone visit which will be billed at the hourly rate.  Note that many insurance companies do not reimburse phone or video visits

 Unpaid Bills

Bills that are more than 30 days past due begin to accrue interest at a rate of 1.6% per month.  If the account is over 90 days past due you will be sent notice requesting payment.  If there is no good faith attempt to pay off the balance of your bill, please be advised that your bill may be sent to a collections agency.  This may incur extra charges as well as negatively affect your confidentiality, privacy and credit history.  Balances outstanding for more than 180 days may result in termination of clinical services.  

I hereby acknowledge that I have been given a copy of or access to this Treatment Agreement and the Notice of Privacy Practices

I hereby give consent for Dr. Fink to treat myself/my child.

Patient Name and DOB: _______________________________________________________________________________

Patient Date of Birth: ______ / ______ / __________

Patient or Patient Representative Name (Printed) and Relationship to Patient

 ____________________________________________________________________________________________________

Patient or Patient Representative Signature and Date Signed

_____________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

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