Patient Forms

Fill out all of our forms digitally.

1

Patient Enrollment

4

Program Responsibilities & Authorizations

7

Health Questionnaire

10

ADHD Questionnaire

2

No Harm Contract

5

HIPAA Privacy Authorization

8

Mood Questionnaire

3

Text Consent

6

Medical History

9

Anxiety Quetionnaire

Capeside Patient Policies

The following  policies have been adopted by Capeside, please review and maintain these policies for referencing,  any staff member will more than happy to answer questions, or concerns you may have regarding these policies.  

Completion of Forms Fee is $25.00 payable prior to completion of forms.

  1. Insurance Filing:      Psychiatry Only

    • Co-pays are collected at time  of visit (if unable to pay the Co-pay the appointment will be rescheduled-no exceptions)

    • Credit Cards are accepted for Co-pay amounts

    • We will file your Insurance to which we are not In Net Work: However; you could have an Out of Net Work extended Expense. 

      1. Insurance information that has been changed or updated must be kept updated in our system, if not the balance due becomes your responsibility for services rendered.  (you can submit a re-file claim)

      2. Insurance does not guarantee payment in full.  Services deemed medically unnecessary by the insurance carrier become your responsibility.

      3. Capeside’s Billing Company will assist you with filing insurance to a secondary or tertiary company.

  2. Self-Pay Accounts:  

    • All accounts that are self-pay must be paid at time of services rendered

    • Accounts with an outstanding balance must be paid in full within 60 days after services rendered unless a payment schedule has been set up with the administration team.

    • Checks are accepted for Psychiatry only services

    • Credits are accepted for self-pay payments

  3. Statement of Accounts:

    • Capeside will send out a statement to the address on file once payment has /or has not been received from your insurance carrier.  In the event your payment is not received within 30 days, you will receive a second notification of past due amount owed, then your account will be placed in collections.

  4. Appointments:  Require 24 Hours Notice for any cancellation

    • A $75.00 Cancellation fee is processed for any appointment that does not cancel within a 24 hour window, and must be paid at your next appointment.

    • If you are 15 minutes late for your scheduled appointment you may be asked to reschedule.

  5. After Hours:

    • Emergencies Dial 911

Phone: 877-241-2468   

Fax: 910-399-2190

Virtual Mental Health Groups

Monday 11 am - 12 pm, Wednesday 1 - 2 pm

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© 2019 by Capeside Psychiatry

For Life-Threatening Emergencies Call 911