Policies

Learn about all of our practice policies, from appointments to phone calls

Divorced parents with joint custody must provide a copy of the custody agreement for new patients noting which parent has medical decision-making authority.

Appointments

This policy covers all services provided at Impireum, including all specialized treatments.

APPOINTMENT POLICY CONSENT FORM

At Impireum^®, we are committed to providing high-quality care and ensuring fair access to healthcare services for all patients. To maintain efficiency and respect the time of both our patients and providers, please review and consent to the following appointment and cancellation policies:

General Appointment Policy

This policy applies to all services provided at Impireum, including specialized treatments such as Neurofeedback and TMS therapy.
Patients are not allowed to double-book appointments within the same week. If double-booked appointments are identified, both will be removed from the scheduler.
Pre-Appointment Check-In Policy

To ensure efficient and timely care, all patients must complete a pre-appointment check-in process 48 hours prior to their scheduled appointment.

Requirements:
1. Complete the online self-check-in via the patient portal.
2. Maintain a valid credit card on file for payment processing.
3. Ensure all consent forms are signed and up-to-date.

1. Consequences of Incomplete Check-In:

Appointments will be automatically canceled if the check-in process is not completed 48 hours in advance.
Patients may reschedule through the patient portal or by contacting our office at 346-361-0100.

2. Cancellation and No-Show Policy

A. Psychiatry and Psychotherapy Appointments:

Cancellations made less than 48 hours in advance or failure to attend an appointment will be treated as a late cancellation or No-Show.
Fees for late cancellations or No-Shows:
1. Psychiatry: $175.00
2. Psychotherapy: $150.00

3. Missed Appointment Limits:

A. Patients who accrue (3) no-show appointments within a 12-month period will be charged the above fees and may receive a discharge letter from the practice.

4. Same-Day No-Show Fee Policy

Patients who fail to attend their scheduled appointment without providing at least 24 hours’ notice will be charged a same-day No-Show fee:
1. Psychiatry: $175.00
2. Therapy: $150.00

Waiver Policy:
1. One same-day No-Show fee will be waived per patient every 12 months.
2. Patients who accrue (3) no-show appointments within a 12-month period will be charged the above fees and may receive a discharge letter from the practice.

5. Courtesy Reminders

Our appointment system sends several reminder notifications before all appointments. However, it remains the patient’s responsibility to attend or cancel appointments in a timely manner.

6. Purpose of Policies

These policies are in place to:

Ensure fair access to healthcare services for all patients.
Minimize disruptions caused by No-Shows and late cancellations.
Respect the time of our providers and other patients.

Questions and Contact

We appreciate you choosing Impireum for your mental health care. If you have any questions regarding this payment policy or need further assistance, please contact us at 346-361-0100 or visit our website at www.impireum.com.

Thank you for trusting us with your mental health care needs.

Impireum®
Your Partner in Mental Health Care

Records and Forms

At Impireum^®, we are committed to providing timely and accurate documentation to support our patients’ needs. To ensure efficiency and fairness, we have established the following Document Requests Policy. By signing this form, you acknowledge your understanding and agreement to comply with the policy outlined below.

I. Document Requests Guidelines

1. Routine Requests:

Routine school or work excuses are available upon request at the end of your appointment.
Records can be pulled and uploaded to the Patient Portal upon your request.

2. Processing Time:

Please allow 3-5 business days to complete document requests

3. Brief Forms During Appointments:

If time permits, brief forms (e.g., absentee notes, accommodation letters) requiring less than 5 minutes to complete may be addressed during your scheduled appointment at no additional charge.
Notify the front desk at the beginning of your appointment if these forms are required.

4. Longer Forms and Letters:

Forms and letters requiring more time will be completed outside of your appointment. Fees are based on the time required to complete the request as follows:
- Simple (less than 5 minutes): No Charge
- Moderate (5-15 minutes): $50.00
- Lengthy (15-30 minutes): $100.00
- Complex (30-60 minutes): $200.00
- Special Complex (over 60 minutes): $200.00/hour

5. Printing, Faxing, or Mailing Records:

If records must be printed, faxed, or mailed, a fee of 25 for the first 20 pages∗∗and∗∗50 for each additional page will apply.

II. Questions and Contact

Thank you for trusting us with your mental health care needs.

Impireum®
Your Partner in Mental Health Care

Payment and Credit/Debit Card Policy

At Impireum®, we are committed to providing accessible and high-quality mental health services. To ensure transparency, please review our payment policy regarding insurance and self-pay services:

Insurance Policy

1. Insurance Coverage:

We proudly accept PPO and Managed Care HMO plans for Psychiatry (medication management) and insurance-approved TMS Therapy services ONLY.

Accepted insurance providers include:

Aetna
Blue Cross Blue Shield (BCBS)
Cigna
UnitedHealthcare (UHC)
Humana
Medicare
Tricare
Triwest

2. Insurance Verification:

As a courtesy, we verify your benefits with your insurance company. However, a quote of benefits is not a guarantee of benefits or payment. Your claim will process according to your plan. If your claim processes differently than the benefits quoted, it is your responsibility to contact your insurance carrier for clarification.

3. Payment Responsibilities:

Payment for deductibles, copays, and/or coinsurance is due at the time of check-in unless prior financial arrangements have been made.
If the amount collected at check-in is incorrect, any outstanding balances will be billed and charged. If there is a credit, you will be refunded promptly.
Please note that being referred to our clinic by another physician does not guarantee insurance coverage for our services.

4. Patient Responsibility:

You are 100% responsible for all charges incurred. Verification of benefits or a physician’s referral does not guarantee payment.

4. Patient Responsibility:

You are 100% responsible for all charges incurred. Verification of benefits or a physician’s referral does not guarantee payment.

5. Contacting Your Insurance:

We highly recommend that you contact your insurance carrier to understand your coverage for behavioral/mental health services. Do not assume you will not owe anything if you have multiple insurance policies.

Self-Pay Policy

We offer the following services on a self-pay* basis only:

1. Therapeutic Counseling:

Individual Therapy:
1. Initial Session: $200.00
2. Follow-up Sessions: $150.00
Family Therapy: $250.00 per session
Group Therapy: $600.00 per 10-week program

2. Neurofeedback:

375. Initial Brain Mapping: $375.00
376. Neurofeedback Sessions: $150.00 per session

ADHD Testing (TOVA):

175. $175.00 per test

* Note: At your request, the practice can provide you with a detailed CMS 1500 medical receipt, also known as a superbill, to submit to your insurance company for reimbursement. As always, you are encouraged to check with your insurance carrier directly to inquire about what is covered under your specific plan.

Payment Methods

We accept the following payment methods:

American Express
Mastercard
VISA
Google Pay
Apple Pay
Discover

Payment Processing

All payments will be processed electronically and made available via the patient portal at impireum.com.
No paper invoices will be mailed to patients

Credit/Debit Card on File

All patients must maintain a valid credit or debit card on file.
Failure to maintain a valid card on file may result in the cancellation of future appointments.

Authorization

This authorization applies to all payments not covered by your insurance carrier for services provided by Impireum^®.

Questions and Contact

Thank you for trusting us with your mental health care needs.

Impireum®
Your Partner in Mental Health Care

Telehealth/Telemedicine

At Impireum®, we are dedicated to providing accessible and convenient mental health care through our telehealth/telemedicine services. Please carefully review the following policies and guidelines. By signing this form, you acknowledge your understanding and consent to participate in telemedicine services.

I. Consent to Telemedicine Services

I consent to participate in telemedicine services provided by Impireum® (Practice) as part of my psychiatric treatment. I understand that telemedicine involves the use of interactive audio, video, or data communications for health care delivery, assessment, diagnosis, consultation, and treatment.

I further understand that telemedicine may involve the communication of my mental health information, both orally and visually, to other health care practitioners located in the state of Texas. I acknowledge that telemedicine provides access to mental health services that may not otherwise be available due to mental health, physical, resource, or geographic limitations.

II. Patient Rights

Right to Withdraw: I have the right to withdraw my consent to telemedicine services at any time.
Risks and Limitations: I understand that telemedicine has risks, including technical failures that may disrupt or distort the transmission of my medical information.
Completeness of Care: I acknowledge that telemedicine services may not be as complete as face-to-face services. If my provider determines that I would benefit more from in-person care, I will be referred to a provider in my geographic area.
No Guaranteed Results: I understand that while telemedicine may be beneficial, results cannot be guaranteed.
Access to Records: I have the right to access my mental health records in accordance with Texas state law.

III. Preparing for Telehealth Appointments

DO’s:

You will receive a Telemedicine Go To Meeting Provider link the day prior to your appointment. Contact the office immediately if you do not receive the link.
Use the latest version of Google Chrome for optimal performance.
Ensure your device is fully charged and check your audio and video settings.
Select a well-lit, private, and confidential space for your session.
Ensure no one else is within hearing range during the session.
Prepare a list of questions and have prescriptions or supplements on hand.
Log in 5 minutes prior to your appointment.
Appointments will be marked as a “no-show” if you are more than 10 minutes late, and a no-show fee will apply.

DON’Ts:

Do not attend telemedicine sessions while in a moving vehicle for safety reasons.
Do not allow unauthorized individuals to be present during your session.
Minors must have a legal guardian or adult present during all sessions.

IV. Safety and Privacy

Telehealth sessions will be terminated immediately if the patient is in a moving vehicle or if unauthorized individuals are present.
Impireum’s telemedicine platform is HIPAA-compliant to protect your privacy and confidentiality.

V. Technology Requirements

Patients must have a functional device with a camera (laptop, PC, tablet, or smartphone) and a broadband Internet connection or a reliable cellular connection.
Additional applications or software may need to be downloaded to access the telemedicine platform.
In case of technology failure, patients should contact Impireum® by phone to coordinate alternative methods of treatment.

VI. Video/Audio Recording

Impireum® may record telemedicine sessions without prior permission as part of its general practice.

VII. Financial Obligations

1. Insurance:

Patients are responsible for contacting their insurance company to determine telemedicine coverage and out-of-pocket costs.
I authorize insurance benefits to be paid directly to Impireum® and consent to the release of information required for claim processing.

2. Self-Pay:

I understand the fees associated with telemedicine appointments and agree to pay at the time of service.
I am responsible for cancelled telemedicine appointments in accordance with Impireum’s cancellation policy.

3. Payment Methods:

Fees for telemedicine services must be paid via credit or debit card.
My card will be billed on the same day as my scheduled appointment. If my card is declined, my appointment will be canceled.

VIII. Scheduling and Emergencies

Telemedicine appointments are scheduled based on the provider’s normal clinic hours.
Telemedicine services are considered outpatient care and are not a substitute for emergency or crisis services.
For emergencies, patients should contact their local crisis line or dial 911.

IX. Confidentiality

The confidentiality of medical information disclosed during telemedicine sessions is protected under the same laws as in-person services.
Exceptions to confidentiality include mandatory reporting of child, elder, or dependent adult abuse, expressed threats of violence, or legal proceedings involving the patient’s mental or emotional state.

X. Questions and Contact

Thank you for trusting us with your mental health care needs.

Impireum®
Your Partner in Mental Health Care

Medication Management

Medication Management Services are a spectrum of patient-centered, pharmacist-provided, collaborative services focusing on medication appropriateness, effectiveness, safety, and adherence to improve health outcomes. It is a service that is individualized for a specific patient, focusing on their needs and concerns, which also involves the patient in the care process.

Impireum’s appointment policies for medication management:

Medication Management Services: Impireum’s Medication Management Services are designed to provide patient-centered and collaborative care focused on medication appropriateness, effectiveness, safety, and adherence. These services aim to improve overall health outcomes by tailoring treatment to individual patient needs and involving patients in the care process.
Refill Requests: Impireum does not accept or process prescription refill requests via phone calls or faxes to streamline the process and ensure accurate documentation. Patients are required to submit refill requests through their designated Patient Portal.
Refill Timing and Appointments: Providers typically prescribe enough refills to cover patients until their next appointment. If a patient misses or cancels an appointment, a partial refill of the requested medication may be provided until the upcoming at the doctor’s discretion. It is important to note that medication changes or adjustments cannot be made without an appointment.
Refill Processing Time: Patients should allow at least 3 business days to process refill requests. Refill requests submitted after 3:00 pm will be reviewed the next business day.
Provider Discretion: Impireum reserves the right to deny refill requests if there are concerns of medication abuse or if patients are not taking their prescribed medication as directed.
Initial Follow-Up Appointments: After the initial appointment, the first psychiatric follow-up visit will be scheduled within the next two weeks or the soonest available appointment slot.
Timeframe for Refills: Refills will only be provided to patients seen by an Impireum clinician within the last three months. This policy ensures ongoing assessment and monitoring of patient’s medication needs.
Controlled Substances: Patients receiving controlled substances will not be provided with refills or bridge prescriptions until a healthcare provider has seen them. Parental Presence: For patients under the age of 18, it is required that parents or legal guardians be present during appointments.
Medication Limits: Impireum has specific limitations on certain medications. For example, benzodiazepines are typically prescribed for a maximum of six (6) weeks, and sleeping pills (Z drugs) are limited to a maximum of 20 days per month.
Stimulants and Sedatives: Stimulants and sedatives will not be prescribed to the same patient. Patients may receive either one stimulant or one sedative based on their treatment plan.
Preferred Medication Forms: Long-acting stimulants are generally preferred over instant-release stimulants. Sometimes, a combination of a long-acting dose and an instant-release dose may be prescribed.
Timely Refill Requests: It is highly recommended that patients do not wait until the last minute to request refills to avoid any potential gaps in the medication supply.

These policies are in place to ensure safe and effective medication management, promote responsible prescribing practices, and prioritize patient well-being. Should you have any further questions or require additional clarification, please feel free to ask.

Patient Portal Medication Refill Requests:

The Patient Portal is an online platform allowing patients to access their health information securely, communicate with healthcare providers, and manage various aspects of their care. It is a convenient and efficient way to interact with Impireum and submit refill requests for medication management. Here are some additional details about the Patient Portal and how to submit refill requests:

Accessing the Patient Portal: To access it, patients must create an account, typically providing their personal information and receiving login credentials. The exact process may vary depending on Impireum’s specific portal system. Patients may receive instructions on how to sign up for the portal during their initial appointment or through other communication channels.
Features of the Patient Portal: Once logged in, patients can access a range of features and services within the Patient Portal. These may include viewing upcoming appointments, accessing medical records, communicating securely with healthcare providers, and submitting refill requests for medication management.
Submitting Refill Requests: To submit a refill request through the Patient Portal, patients should navigate to the designated section or feature dedicated to refill requests. This section may be labeled as “Medication Refills” or something similar. Patients will typically find a form or template where they can enter specific details regarding their medication needs.
Required Information: Patients may need to provide certain information to ensure accurate processing when submitting a refill request. This can include the medication name, dosage, frequency, and specific instructions or notes related to the refill request. It’s important to fill out the form accurately and completely to facilitate the refill process.
Communication and Confirmation: Patients may receive confirmation or acknowledgment of their request after submitting the refill request through the Patient Portal. This can be in the form of an on-screen message, an email notification, or both. It’s advisable to retain any confirmation messages or emails for future reference.
Review and Processing Time: Once a refill request is submitted, healthcare providers at Impireum will review it, evaluate its appropriateness, and determine if it aligns with the patient’s treatment plan. This process typically takes at least (three) 3 business days, as mentioned previously. Patients should allow sufficient time for the refill request to be processed and filled.
Follow-Up Communication: Healthcare providers may need to contact patients for additional information or clarification regarding the refill request. Patients should be attentive to any communication from Impireum and promptly respond to any inquiries to expedite the refill process.

By utilizing the Patient Portal and following the designated refill request process, patients can conveniently submit their medication refill requests, ensuring efficient communication and timely fulfillment of their prescription needs.

Scheduled Phone Calls

At Impireum®, we strive to provide the highest quality care to all our patients. To ensure efficient communication and equitable access to our providers, we have established the following Phone Call Policy. By signing this form, you acknowledge your understanding and agreement to adhere to the policy outlined below.

I. Emergency Situations

If your call is an emergency, please call 911 or go to the nearest emergency room immediately. Our office is not equipped to handle emergency situations via phone.

II. Provider Availability

1. Limited Availability During Office Hours:

Our providers are often in session with patients/clients during the day and may not be immediately available to take calls.
If you need to contact a provider between appointments, please submit your request via the Patient Clinical Request Formor the Patient Portal, specifying the nature of your call.
Providers will respond to messages as soon as possible. Based on the nature of your request, you may be asked to schedule an earlier follow-up appointment.

III. Phone Consultation Charges

2. Charges for Extended Phone Consultations:

Phone calls or extended telephone consultations during office hours that would otherwise require an office visit will incur a charge.
Fees are determined based on your insurance policy rate, where applicable, or the Impireum self-pay rate of 00 per 5 minutes∗∗,with aminimum charge of 25.00 per 5 minutes,

IV. Questions and Contact

Thank you for trusting us with your mental health care needs.

Impireum®
Your Partner in Mental Health Care