In order for me to provide the best care possible, I want my patients to have as much pertinent information as possible. If you have any questions or concerns about the healthcare or business practices of this office, please feel free to discuss them with me.
Services you receive in this office are confidential, except in the circumstances listed below:
In circumstances other than these, I will not release information about your treatment without your authorization.
Messages left on voicemail are retrieved regularly and calls are returned as soon as possible. If you need more rapid attention for your own or someone else's safety, do not delay while waiting for me to return your telephone call. Please call 9-1-1 or report to the nearest hospital emergency room. The suicide hotline for Travis County is 512-472-HELP (512-472-4357). You may also call Austin Oaks Hospital (512-440-4800), Cross Creek Hospital (844-587-0195), or Rock Springs Hospital (512-819-9400) in the event you feel you need psychiatric hospitalization.
After-hours coverage is provided per the instructions on the clinic's voicemail. The after-hours doctor is for emergencies only, not for routine refill requests. No new controlled substances will be called in after-hours or by on-call doctors.
An electronic record (file) is kept of services you receive in this office. You have a right to see the record and receive a copy of it upon request. You may ask that factual errors in the record be corrected. You may authorize in writing that copies of the record be released to entities you designate, at your expense, according to charges stipulated by the state law of Texas. Under certain circumstances where seeing the record may put a patient or other person at risk, I may redact certain information in the record and/or require that you review the record in consultation with another healthcare provider. You may receive an accounting of non-routine uses and disclosures of your record.
I make reasonable efforts to prevent access and disclosure to unauthorized personnel. I keep an ongoing log of potential risks and the physical and electronic safeguards implemented to limit these risks. I require my business associates to abide by all applicable privacy regulations.
Only your health insurance plan can describe your benefits to you or verify provider eligibility. My administrative staff will help you obtain this information from your health insurance plan, but you must contact the health insurance plan directly for verification. If charges are denied by a health insurance plan they become entirely your responsibility, even if you had understood from your health insurance plan that the charges would be paid by them. If we are not a provider for your insurance plan (i.e. not a preferred provider), you will be given a receipt sufficient for you to directly bill your insurance for reimbursement. You will need to pay for your appointment in full at the time of service. We can take credit cards, checks, and cash. There will be a $35.00 fee for all returned checks.
We do not accept Medicaid. Please inform the administrative assistant if you participate in this plan. We reserve the right to terminate patients who are unable to meet these financial obligations.
Payment for charges not covered by your health insurance plan (including co-payment, co-insurance, and deductible amounts) is due in full at the time services are provided unless prior arrangements have been made. Fees are $310.00 for the initial appointment. Follow-up appointments will typically range from $130 - $245; inquire for details. These fees are subject to change; however, any changes will be discussed with you. Fees for other services are by request.
It is important that you discuss with me any financial hardship that you may have. Doing so may allow us to arrive at a mutually agreeable payment plan that allows the continuation of your treatment. If this cannot be accomplished, seriously delinquent accounts may be referred to a collection agency and we may have to terminate our relationship as provider and patient. Information necessary to effect collection will be released to the collection agent. Should it become necessary to file suit in this context, you agree to pay reasonable attorney fees. A late fee of $10 will be charged on balances more than thirty (30) days past due, and for each thirty (30) days thereafter.
Failure to keep a scheduled appointment will result in a charge for the full fee of the scheduled appointment, unless you cancel at least forty eight (48) hours prior to the appointment time. Please note that insurance health plans do not pay for missed appointments, these charges will be entirely your responsibility. Three missed appointments or no-shows in a 12 month period may result in termination from the practice. Patients cancelling or not showing twice for their initial assessment will not be scheduled for a third intake appointment.
Please make every effort to arrive on time to your appointment. Anyone arriving more than 10 minutes late may be rescheduled for another appointment, depending on availability of the doctor. We will make every effort to notify you of upcoming appointments; however, it is still your responsibility to attend your scheduled appointments. No assessments for disability will be provided at the initial assessment. Any forms requiring more than a signature from the doctor will need to be filled out during an additional, scheduled appointment in order to accurately complete forms with the patient present.
Please consider carefully how you would like to be contacted for appointments, rescheduling, and general matters. We will need at least one emergency contact for all patients.
If you have any questions or concerns about administrative or business matters in this office, please discuss them with me.
If you have any questions or concerns about your treatment, you are encouraged to discuss them with me. In addition, or instead, the following avenues are available:
Due to the partnership of the doctor-patient relationship, it is expected that the patient will follow prescribed treatments and instructions, including, but not limited to taking medications as prescribed, attending therapy modalities recommended, and obtaining lab work. Patients who are consistently non-compliant with treatment recommendations, follow-up, and lab draws may be terminated due to the risks associated with non-compliance. There is an expectation that the patient will be forthcoming and honest in all interactions. If a patient deliberately misleads staff or the doctor, it will be decided on a case by case basis if termination from the clinic is warranted.
In an effort to provide a safe environment for everyone in the office, direct or indirect threats will be grounds for immediate termination from the clinic. This includes, but is not limited to: threatening phone calls, yelling or screaming in person or over the phone, vulgar or profane language, intimidation, or threats. Additionally, we will not tolerate deliberate property destruction.
This practice will not prescribe pain medications. Please see your primary care physician or pain specialist for narcotics. This practice will prescribe limited benzodiazepines and stimulants. We can provide names of other providers if this will not meet your needs. It is the responsibility of the patient to know when a refill is needed. Please contact your pharmacy during regular business hours to fax the office a refill request at least 48 hours in advance to ensure you receive your refill on time. If you have run out of medication during normal business hours, you can either have your pharmacy fax a request or call the office directly. Refill requests made after hours, during the weekend, or major holidays will be filled the next business day, so please plan accordingly. It is at the discretion of the doctor whether or not a medication will be refilled without an appointment. Certain scheduled medications require an appointment for each refill to ensure medical necessity.
Office policies may be updated from time to time without notice. The current version of our office policies will be available in the office or from our web page - www.drsierk.com