Patient Information Consent and Financial Policy

Welcome to Healthy Mind. We appreciate the opportunity to work with you. The following information is provided for your benefit so that we may serve you better. Please read carefully and sign at the bottom. You will be given a copy for your records.

Fees for services: which include unpaid balances, deductibles; copayments and fees are due at the time of your visit. We accept cash, debit, and all major credit cards.

We ask that you arrive on-time for your appointments. This will facilitate our ability to see you as scheduled. Patients arriving past the appointment time may result in rescheduling.

Patients are asked to cancel at least 24 hours in advance of the scheduled appointment time.

Please provide us with any change regarding your address, phone number or insurance information as soon as possible.

Must be seen monthly for refills.

Urine prescription monitoring may be conducted on all new patients and periodically on patients taking controlled substances. Patients with drug screens positive for elicit substances will not be prescribed medications that are potentially habit forming.

In a life-threating emergency, please call 911. For urgent not-emergency matters please call our office number 609-479-1931 and leave a message. If needed the provider on call will return your call as soon as possible.

Requests for copies of your medical records must be made in writing on a form provided by our office. Our office will respond within 15 business days to a properly completed written request.

The provider reserves the right to terminate the provider/patient relationship at their discretion. Reasons for termination may include, but are not limited to: failure to comply with treatment plan, ultimately unpaid balances, history of missed appointments, tampering or refusal of drug screen, verbal abuse of staff and lack of a good fit. The patient (or the patient’s legal representative) has the right to terminate treatment at his/her discretion. Upon either party’s decision to terminate the relationship, the provider will continue care for at least 30 days and recommend more appropriate resources.

Dr. Harriet Asamoah and the providers/staff with Healthy Mind do not participate in court-related matters, such as divorce or child support cases. However, if court-related work is required, the practices’ cost related to that work is the sole responsibility of the patient and/or their responsible party. These matters include but are not limited to: preparation, communication with involved parties, depositions, testimony, standby efforts, attorney fees, and other cost incurred as a direct result of the matter.

In the event of a delinquent account balance, I will be responsible for all collection fees assessed by the collection agency onto the account.

I consent to evaluation and treatment of myself.