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Client Checklist & Policies
First-Time Visits
When you come to our office for the first time as a new patient, we’ll ask you to complete some initial forms, including an Authorization and a Consent for Treatment form, which will be sent to you electronically using our digital patient check-in platform.
All required registration and practice forms have to be completed prior to being seen.
If we do not have your completed forms on file prior to your visits we may ask you to reschedule your appointment.
We ask that you give special consideration to the Informed Consent form, which contains important information regarding your privacy, the psychological service offered, and insurance and billing information. We expect it will take 30 minutes to complete them.
Should you have additional questions about our procedures, matters of confidentiality, or insurance and billing, please ask us to clarify.
Office Policies
Financial Policy — This form advises patients of their complete financial responsibility for all medical services received without regard to insurance eligibility or coverage determinations.
Notice of Privacy Practices — Describes how health information about you (as a patient of this Care Center) may be used and disclosed, and how you can get access to your individually identifiable health information. Please review this notice carefully.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) – This is a federal law that required the creation of national standards to protect sensitive patient health information from being disclosed without the patient’s consent or knowledge. The US Department of Health and Human Services (HHS) issued the HIPAA Privacy Rule to implement the requirements of HIPAA. The HIPAA Security Rule protects a subset of information covered by the Privacy Rule.
Before Your Visit…
To expedite your first appointment, here’s a helpful checklist of thing to do before your visit.
Complete patient registrations forms via AdvancedMD
Upload your insurance card
Upload your photo ID
Add the information for your copay
Mandatory Forms - All Clients, As Needed
Notice of Privacy Practices
New Patient Intake
Financial Policy
Consent for Phone, Email & SMS Text Messaging
Parental Consent Form for Minors Under 15
Detailed Explanation of Consent for Psychiatric Evaluation & Treatment
MEDICATION MANAGMENT CLIENTS: RX Refill - Controlled Substance Agreement
Single-Session Therapy Clients Only
Single-Session (SST) Therapy Consent Form
Miscellaneous Forms - All Clients, As Needed
Self-Pay Agreement Form
Informed Consent for Telehealth Services
Supervisory Disclosure Form
Consent to Release & Receive Confidential Information
Know someone who could use our help?
Late Arrivals, Cancellations, No-Shows & Dismissal
Late Arrivals: If you are more than 7 minutes late for a scheduled appointment, you may be asked to reschedule your appointment and a fee will incur on your account. We will try our best to accommodate late-comers as best as possible, but cannot compromise on the quality and timely care provided to our other clients.
Cancellations: If you are unable to keep a scheduled appointment, you must call or email at least forty-eight (48) business hours in advance or we may consider you a “no-show” and a fee will incur on your account. Please note that the 48-hour notice period excludes Fridays after business hours, as well as weekends.*
No-Shows: If you miss your appointment without prior notice, you will be charged a fee on your account. Fees associated with missing appointments cannot be billed to insurance.
Here are the fees based on the type of appointment:
- New Therapy Appointments: $125.00
- Follow-Up Therapy Appointments: $125.00
- New Medication Management Appointments: $150.00
- Follow-Up Medication Management Appointments: $100.00
- Testing Appointments: $400.00
Please call 240-750-6467 or email appointments@orchardmentalhealth.com if you need to cancel or reschedule an appointment.
*=For example, if a client leaves a message after 5pm Eastern time on a Friday, cancelling their appointment for the upcoming Monday, the client will incur a fee.
In crisis or need immediate help?
Call 988 or go to your nearest ER.
Services
Adolescent Psychotherapy
Adult Psychotherapy
Assessments & Evaluation
Child Psychotherapy
Cognitive Behavioral Therapy
Couples Therapy
Family Therapy & Parent Coaching
Genetic Testing
Group Therapy
Medication Management
Play Therapy
Single-Session Therapy
Teletherapy
Accepted Insurance*
Aetna
Carefirst / Blue Cross Blue Shield
Cigna
Humana / Tricare
Johns Hopkins Health Plans
Medicaid
Medicare
Optum / UnitedHealthcare
*Varies by service
Partner Resources
Orchard Mental Health Group
Contact Us
M-F, 9am-5pm Eastern Time
Phone: 240- 750-6467
Fax: 240-912-7835
contact@orchardmentalhealth.com
9707 Key West Avenue, Suite #100 Rockville, MD 20850